DCFS Suspected Child Abuse/Neglect Referral Information Request Instructions
This form contains 23 fields organized into 10 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Concerns | ||
| Domestic Violence | Checkbox |
Check this box if domestic violence has been noted as an additional concern.
|
| Substance Abuse | Checkbox |
Check this box if substance abuse has been noted as an additional concern.
|
| Mental Illness | Checkbox |
Check this box if mental illness has been noted as an additional concern.
|
| Caretaker Information | ||
| Caretaker's Name | Text |
Please enter the full name of the caretaker.
|
| Caretaker's Relationship | Text |
Please enter the relationship of the caretaker to the child.
|
| Case Number and Parent's Name | ||
| Case Number | Text |
Provide the case number for this referral.
|
| Parent's Name | Text |
Enter the full name of the parent.
|
| Child's Name and Referral Date | ||
| Child's Name | Text |
Please enter the full name of the child.
|
| Date of Referral | Date |
Please provide the date when the referral was made.
|
| DCFS Contact Information | ||
| DCFS Contact Name | Text |
Provide the full name of the DCFS contact person.
|
| DCFS Contact Telephone | Text |
Provide the telephone number for the DCFS contact.
|
| DCFS Contact Fax | Text |
Provide the fax number for the DCFS contact.
|
| General | ||
| Text15 | Text | |
| Text16 | Text | |
| Text17 | Text | |
| Text18 | Text | |
| Noted Injuries or Concerns | ||
| Noted Injury/Concern 1 | Text |
Provide details for the first noted injury or concern.
|
| Noted Injury/Concern 2 | Text |
Provide details for the second noted injury or concern.
|
| Noted Injury/Concern 3 | Text |
Provide details for the third noted injury or concern.
|
| Parent/Caretaker Explanation of Injury | ||
| Parent/Caretaker Explanation | Text |
Enter the explanation provided by the parent or caretaker regarding the child's injury or injuries.
|
| Response Date | ||
| Response Date | Date |
Provide the date by which a response is requested for this form.
|
| Supervisor Information | ||
| Supervisor Name | Text |
Please enter the full name of the supervisor.
|
| Supervisor Telephone | Text |
Please provide the telephone number of the supervisor.
|