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Click ‘Get Form’ to open it in the editor.
Begin by entering the date of your report at the top of the form. This is crucial for tracking purposes.
Fill in the child's name and birth date. If reporting multiple children, list their names and birth dates on the reverse side.
Provide the street address, city, and zip code of the child. This information helps in identifying the location for follow-up.
Enter the parent or custodian's name and address if it differs from that of the child.
Answer questions regarding injuries or signs of abuse/neglect, detailing how you became aware of these issues.
Indicate any previous evidence of abuse/neglect and provide details if applicable.
List names and addresses of other individuals who may have relevant information about this case.
Complete your relationship to the child(ren) and any actions you have taken or recommend regarding this situation.
Finally, print your name, sign, and include your title and organization/agency before submitting.

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