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Child Maltreatment Reporting Form

  1. Child Maltreatment Reporting Form

  2. 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 Social Worker, please call Chisago County Child Protection Intake at 651-213-5672 and the intake specialist will assist you.

  3. If Mandated Reporter enter Agency Name, otherwise enter N/A.

  4. If Mandated Reporter use Agency Address.

  5. Do the parents know you are making a CP report?*

  6. Does the child know you are making a CP report?*

  7. MOTHER'S INFORMATION

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

  9. FATHER'S INFORMATION

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

  11. MOTHER'S HOME. Other Adults residing in the home (i.e. step parent, grandparents and so on):

  12. FATHER'S HOME. Other Adults residing in the home (i.e. step parent, grandparents and so on):

  13. Is the child or anyone in the family of American Indian or Alaskan heritage?*

  14. Gender

  15. Gender

  16. Gender

  17. Gender

  18. Gender

  19. Who has the child identified as the alleged perpetrator of abuse/neglect (if any, please don't specifically ask the child):

  20. Did you place a phone call to Child Protection Intake?*

  21. If you did NOT call Child Protection Intake, please enter N/A.

  22. If you called Child Protection Intake this field is required.

  23. Maltreatment of Minors Act (626.556) requires mandated reporters to provide both verbal and written notice to child protection.

  24. 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.

  25. 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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