PERSONNEL
402.2E1 - SUSPECTED CHILD ABUSE REPORTING FORM
See Attached Form for current reporting form.
Contents of attached form:
Iowa Department of Human Services
SUSPECTED CHILD ABUSE REPORTING FORM
This form may be used as the written report which the law requires all mandated reports to file with the Department of Human Services, following an oral report of suspected child abuse. Fill in as much information under each category as is known. Submit the completed form to the local office of the Department of Human Services.
FAMILY INFORMATION
Name of Child ________________________ Age:_____ Date of Birth______________
Address: _______________________________________________________________
Phone: ____________________ School: _____________________ Grade Level: ____
Name of Parent or Guardian: _____________________________ Phone (if different from child’s): __________________
Address (if different than child’s): ___________________________________________
Other Children in the Home:
Name
Birthdate
Condition
INFORMATION ABOUT SUSPECTED ABUSE: In this section, indicate the date of suspected abuse, nature, extent and cause of the suspected abuse: the person(s) thought to be responsible and who conducted the investigation. Use the back of this form if necessary to complete the information as requested above and to identify individuals who have been informed of the child abuse, such as building administrator, supervisor, etc.
REPORTER INFORMATION:
Name and Title or Position: ___________________________________________________________
Office Address: ____________________________________________________________________
Phone: ________________________________________Relationship to Child: _________________
Name (s) of other mandatory reporter (s) who has/have knowledge of the abuse: __________________________________________________________________________________
