This form contains 34 fields organized into 15 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Child Information
Child's Name	Text	Please enter the full name of the child.
Child's Birth Date	Date	Please enter the child's birth date.
Child's Address
Street Address	Text	Please provide the street address of the child.
City	Text	Please provide the city where the child resides.
Zip Code	Text	Please provide the zip code for the child's address.
Details of Abuse/Neglect Occurrence
Abuse/Neglect Occurrence Details	Text	Provide details regarding how and approximately when the abuse or neglect occurred, and explain how you became aware of it.
Explanation of Prior Abuse/Neglect
Explanation of Prior Abuse/Neglect	Text	Provide a detailed explanation of the nature of the prior abuse or neglect, if applicable. Fill only if 'Evidence of Previous Abuse/Neglect - Yes' is 'Yes'. Depends on: Evidence of Previous Abuse/Neglect - Yes
General
Do NOT believe child is in immediate physical danger	Checkbox	Check this box if you do not believe the child is in immediate physical danger.
Information Source
Evidence of Previous Abuse/Neglect - Yes	Checkbox	Check this box if there has been evidence of abuse or neglect involving the child(ren) before now.
Evidence of Previous Abuse/Neglect - No	Checkbox	Check this box if there has been no evidence of abuse or neglect involving the child(ren) before now.
Information Source - Saw Child(ren)	Checkbox	Check this box if you personally saw the child or children related to this report.
Source of Information	Text	Please provide the name of the person from whom you heard about the child(ren). Fill only if 'Heard About Child' is 'Yes'. Depends on: Heard About Child
Injuries or Signs of Abuse/Neglect
Description of Injuries or Signs	Text	Provide a detailed description of any injuries or signs of abuse or neglect observed.
Oral Report Confirmation Details
Oral Report Date	Date	Provide the date when the oral report was made.
Oral Report Time	Time	Provide the time when the oral report was made.
Other Persons with Information
Names and Addresses of Other Persons	Text	Provide the names and addresses of other persons who may be willing to provide information about this case.
Page 2
Second Child's Name	Text	Please provide the full name of the second child, if applicable. Fill only if 'Reporting more than one child' is 'Yes'.
Second Child's Birth Date	Date	Please provide the birth date of the second child. Fill only if 'Second Child's Name' is not empty. Depends on: Second Child's Name
Third Child's Name	Text	Please provide the full name of the third child, if applicable. Fill only if 'Reporting more than one child' is 'Yes'.
Third Child's Birth Date	Date	Please provide the birth date of the third child. Fill only if 'Third Child's Name' is not empty. Depends on: Third Child's Name
Parent/Custodian Information
Parent/Custodian Name	Text	Please enter the full name of the parent or custodian.
Parent/Custodian Address	Text	Please enter the full street address of the parent or custodian, if it is different from the child's address.
Relationship to Child(ren)
Your Relationship to Child(ren)	Text	Please describe your relationship to the child or children.
Report Date
Report Date	Date	Provide the date the report was made.
Reporter Action Recommended or Taken
Reporter Action	Text	Please describe the action the reporter recommended or has taken regarding the suspected child abuse or neglect.
Heard About Child	Checkbox	Check this box if you received information about the child indirectly.
Told Family of Concern	Checkbox	Check this box if you have already informed the child's family of your concern and report to the Department.
Not Told Family of Concern	Checkbox	Check this box if you have not yet informed the child's family of your concern and report to the Department.
Willing to Tell Family	Checkbox	Check this box if you are willing to inform the child's family of your concern and report to the Department.
Not Willing to Tell Family	Checkbox	Check this box if you are not willing to inform the child's family of your concern and report to the Department.
Believe Child in Danger	Checkbox	Check this box if you believe the child is currently in immediate physical danger.
Reporter Information
Reporter Name	Text	Please enter the full printed name of the person completing this report.
Reporter Title	Text	Please enter the professional title of the person completing this report.
Reporter Organization/Agency	Text	Please enter the name of the organization or agency the reporter represents.

Suspected Child Abuse Report Instructions