Michigan health human services 2026

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4.8 out of 5

57 votes

The document is a confidential Special Evaluation Record from the Michigan Department of Health and Human Services, detailing procedures for reporting and evaluating alleged violations related to child welfare licensing. It includes sections for department and reporter information, nature of intake, alleged violations, and recommended regulatory actions. The form must be completed by licensing workers and submitted via email, ensuring compliance with state laws regarding child protection.

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Click ‘Get Form’ to open the Michigan Health Human Services form in the editor.
Begin with Section I, where the Licensing Worker must fill in their name, department, address, and phone number. Ensure all information is accurate for proper processing.
Proceed to Section II to complete the Reporter Information. Fill in the reporter's name, contact details, and nature of intake. Be clear and concise about the reason for contact.
In Section III, document any alleged statute or rule violations. Indicate whether there was noncompliance and recommend regulatory actions as necessary.
Once all sections are completed, email the form to the designated DCWL mailbox at MDHHS-DCWL-259@michigan.gov for submission.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (57 Votes)
2016	4.3 Satisfied (43 Votes)

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