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Child Maltreatment Reporting Form

2. Child Maltreatment Reporting Form
4. Date of Report:*
   Date of Report:
6. If you feel the child/ren is in immediate danger, please call 911. If you are unsure and/or would prefer to speak to a Child Protection Intake Worker, please call Chisago County Child Protection at 651-213-5672. This phone is answered Monday thru Friday from 8:00 a.m. to 4:30 p.m., excluding holidays. If calling after hours, please leave a detailed message and your call will be returned on the next business day.
8. Date of Incident:*
   Date of Incident:
10. Reporter's Name:*
11. Type of Reporter:*

    1. Mandated Reporter
    2. Voluntary Report
13. Agency:*
    If Mandated Reporter enter Agency Name, otherwise enter N/A.
15. Address:*
    If Mandated Reporter use Agency Address.
17. City:*
18. State:*
19. Zip:*
21. Phone: (best number to contact you if there are follow-up questions)*
22. Fax Number:
23. Alternate Phone Number:
25. Email Address:
27. Relationship to the Family:
29. Did you place a phone call to Child Protection Intake?*

    1. Yes
    2. No
30. If yes, whom did you speak with?*
32. Date you called Child Protection Intake?
    Date you called Child Protection Intake?
    If you called Child Protection Intake this field is required.
33. Reporting of Maltreatment of Minors (Chapter 260E) requires mandated reporters to provide both verbal and written notice to child protection.
35. Nature of Problem (including victim's name(s) injuries, and location where incident occurred). Please be as detailed as possible. PLEASE NOTE: Any use of language regarding private body parts or profanity will prevent your report from electronically submitting. If your report requires this type of language, please use the first letter of the word followed by asterisks, and give the specific details in your verbal report when you call Child Protection Intake at 651-213-5672.*
37. Location of child/ren now:*
38. Do the parents know you are making a CP report?*

    1. Yes
    2. No
40. Does the child know you are making a CP report?*

    1. Yes
    2. No
41. Who else have you contacted?
43. Others with information:
45. MOTHER'S INFORMATION
47. Mother's Name:*

    Enter FULL (First, Middle, and Last) Name.

48. Date of Birth:
    Date of Birth:
50. Phone #1 (Preferred):
51. Phone #2 (Alternate):
53. Address:*
55. City:*
56. State:*
57. Zip:*
59. FATHER'S INFORMATION
61. Father's Name:*

    Enter FULL (First, Middle, and Last) Name.

62. Date of Birth:
    Date of Birth:
64. Phone #1 (Preferred):
65. Phone #2 (Alternate):
67. Address:*
69. City:*
70. State:*
71. Zip:*
73. Custodial Parent:
75. MOTHER'S HOME. Other Adults residing in the home (i.e. step parent, grandparents and so on):
77. Name:
78. Date of Birth:
    Date of Birth:
80. Name:
81. Date of Birth:
    Date of Birth:
83. Name:
84. Date of Birth:
    Date of Birth:
88. FATHER'S HOME. Other Adults residing in the home (i.e. step parent, grandparents and so on):
90. Name:
91. Date of Birth:
    Date of Birth:
93. Name:
94. Date of Birth:
    Date of Birth:
96. Name:
97. Date of Birth:
    Date of Birth:
99. Is the child or anyone in the family of American Indian or Alaskan heritage?*

    1. yes
    2. no
100. If yes, which family member:
102. Full Name of Victim (in the home):*
104. Race of Victim:*
     -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHIspanic/LatinoDeclinedUnknown
105. Gender of Victim:*

     1. Male
     2. Female
     3. Other
107. Address:*
109. City*
110. State*
111. Zip*
113. DOB of Victim:*
     DOB of Victim:
114. Estimated Age of Victim (if DOB is unknown):*
116. School/Daycare of Victim:*
120. Full Name of Child 2 (in the home):
122. Race of Child 2:
     -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHispanic/LatinoDeclinedUnknown
123. DOB of Child 2:
     DOB of Child 2:
124. Gender

     1. Male
     2. Female
     3. Other
126. School/Daycare of Child 2:
130. Full Name of Child 3 (in the home):
132. Race of Child 3:
     -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHispanic/LatinoDeclinedUnknown
133. DOB of Child 3:
     DOB of Child 3:
134. Gender

     1. Male
     2. Female
     3. Other
136. School/Daycare of Child 3:
140. Full Name of Child 4 (in the home):
142. Race of Child 4:
     -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHispanic/LatinoDeclinedUnknown
143. DOB of Child 4:
     DOB of Child 4:
144. Gender

     1. Male
     2. Female
     3. Other
146. School/Daycare of Child 4:
150. Full Name of Child 5 (in the home):
152. Race of Child 5:
     -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHispanic/LatinoDeclinedUnknown
153. DOB of Child 5:
     DOB of Child 5:
154. Gender

     1. Male
     2. Female
     3. Other
156. School/Daycare of Child 5:
160. Who has the child identified as the alleged perpetrator of abuse/neglect (if any, please don't specifically ask the child):
162. Name:
163. Phone Number:
165. Address:
167. City:
168. State:
169. Zip:
171. ATTACH FILES: Please attach any pictures (jpeg), pdf, or other documents to support the report. If unable to attach files, fax to 651-213-5686.
173. File #1:
174. File #2:
175. File #3:
176. File #4:
178. Contact Information:
     Chisago County Child Protection Intake -- 313 North Main St, Suite 239 -- Center City, MN 55012 -- Phone: 651-213-5672 -- Fax: 651-213-5686 -- Email: chisagocountyprotectionintake@chisagocounty.us
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