State of Maryland-Child Protective Services REPORT OF SUSPECTED CHILD ABUSE/NEGLECT (see instructions on next page) 1. NAME OF LOCAL DEPARTMENT BEING NOTIFIED ADDRESS ZIP Department of Social Services/ 21921 Protective Services 2. PERSON MAKING REPORT (Name) 3. POSITION/TITLE 4. NAME OF DEPARTMENT/ORGANIZATION ADDRESS ZIP 5. TELEPHONE 6. TYPE OF REFERRAL PHYSICAL ABUSE SEXUAL ABUSE NEGLECT MENTAL INJURY ABUSE MENTAL INJURY - ABUSE – 7. NAME OF CHILD 8. SEX 9. BIRTH DATE 10. RACE 11. ADDRESS (Where CITY STATE ZIP 12. GRADE Child Can Be Seen) 14. NAME OF PERSON RESPONSIBLE FOR CHILDS CARE 14A. AGE/D.O.B. 14B. ADDRESS 14C. TELEPHONE PARENTS/GUARDIAN AGE/D.O.B. ADDRESS TELEPHONE MOTHER: FATHER: GUARDIAN (Specify Relation): 15. NAME OF SUSPECTED ABUSER/NEGLECTOR 16. RELATION 17. AGE/D.O.B. 18. ADDRESS 19. TELEPHONE NATURE EXTENT OF THE CURRENT ABUSE/NEGLECT TO THE CHILD IN QUESTION: EXPLAIN THE CIRCUMSTANCES LEADING TO THE SUSPICION THE CHILD IS AN ABUSE/NEGLECT BICTIM. DESCRIBE ANY INJURY OR RISK. DESCRIBE HOW REPORTER KNOWS INFORMATION. 21. LIST INFORMATION CONCERNING PREVIOUS ABUSE/NEGLECT TO THE CHILDREN/OTHER CHILDREN IN THE FAMILY, INCLUDING PREVIOUS ACTION TAKEN. HOW DOES THE REPORTER KNOW THIS INFORMATION? 22. DESCRIBE INFORMATION KNOWN ABOUT FAMILY FUNCTIONING, RELATIONSHIP BETWEEN PARENT, CARETAKER, OTHER ADULTS IN HOME AND CHILDREN AND LIKELY RESPONSE BY FAMILY TO DISCLOSURE. HOW DOES THE REPORTER KNOW THIS INFORMATION? 23. STATE ANY OTHER AVAILABLE INFORMATION THAT WOULD AID IN ESTABILISHING THE CAUSE OF THE ALLEGED ABUSE/NEGLECT. 24. ARE WEAPONS IN THE HOME OR KNOWN TO BE CARRIED BY 25. IS THERE A HISTORY OF VIOLENCE, DRUGS, MENTAL 26. IF YES TO EIGHER, DESCRIBE IN THE FAMILY OR ACCUSED ABUSER? ILLNESS OR RETALIATION IN THE FAMILY? DETAIL ON SEPARATE SHEET OF Yes No Unknown Yes No Unknown PAPER 27. SIGNATURE OF PERSON REPORTING DATE 28. DATE/HOUR ORAL CONTACT IN LDSS 29. REPORT TAKEN 30. NAME OF LDSS STAFF TO WHOM ORAL REPORT WAS MADE Yes No TEMPLATE VERSION OF DHR/SSA 180 (5/98) Previous editions are obsolete DISTRIBUTION: LDSS Original and one copy – STATES ATTORNEY one copy (Child abuse only) – REPORTER one copy – OFFICE OF STUDENT SERVICES one copy –
State of Maryland-Child Protective Services REPORT OF SUSPECTED CHILD ABUSE/NEGLECT (see instructions on next page) 1. NAME OF LOCAL DEPARTMENT BEING NOTIFIED Department of Social Services/ Protective Services ADDRESS ZIP 21921 2. PERSON MAKING REPORT (Name) 3. POSITION/TITLE 4. NAME OF DEPARTMENT/ORGANIZATION ADDRESS ZIP 5. TELEPHONE 6. TYPE OF REFERRAL PHYSICAL ABUSE SEXUAL ABUSE NEGLECT MENTAL INJURY – ABUSE MENTAL INJURY - ABUSE 7. NAME OF CHILD 8. SEX 9. BIRTH DATE 10. RACE 11. ADDRESS (Where Child Can Be Seen) CITY STATE ZIP 12. GRADE 14. NAME OF PERSON RESPONSIBLE FOR CHILDS CARE 14A. AGE/D.O.B. 14B. ADDRESS 14C. TELEPHONE PARENTS/GUARDIAN AGE/D.O.B. ADDRESS TELEPHONE MOTHER: FATHER: GUARDIAN (Specify Relation): 15. NAME OF SUSPECTED ABUSER/NEGLECTOR 16. RELATION 17. AGE/D.O.B. 18. ADDRESS 19. TELEPHONE NATURE EXTENT OF THE CURRENT ABUSE/NEGLECT TO THE CHILD IN QUESTION: EXPLAIN THE CIRCUMSTANCES LEADING TO THE SUSPICION THE CHILD IS AN ABUSE/NEGLECT BICTIM. DESCRIBE ANY INJURY OR RISK. DESCRIBE HOW REPORTER KNOWS INFORMATION. 21. LIST INFORMATION CONCERNING PREVIOUS ABUSE/NEGLECT TO THE CHILDREN/OTHER CHILDREN IN THE FAMILY, INCLUDING PREVIOUS ACTION TAKEN. HOW DOES THE REPORTER KNOW THIS INFORMATION? 22. DESCRIBE INFORMATION KNOWN ABOUT FAMILY FUNCTIONING, RELATIONSHIP BETWEEN PARENT, CARETAKER, OTHER ADULTS IN HOME AND CHILDREN AND LIKELY RESPONSE BY FAMILY TO DISCLOSURE. HOW DOES THE REPORTER KNOW THIS INFORMATION? 23. STATE ANY OTHER AVAILABLE INFORMATION THAT WOULD AID IN ESTABILISHING THE CAUSE OF THE ALLEGED ABUSE/NEGLECT. 24. ARE WEAPONS IN THE HOME OR KNOWN TO BE CARRIED BY THE FAMILY OR ACCUSED ABUSER? Yes No Unknown 25. IS THERE A HISTORY OF VIOLENCE, DRUGS, MENTAL ILLNESS OR RETALIATION IN THE FAMILY? Yes No Unknown 26. IF YES TO EIGHER, DESCRIBE IN DETAIL ON SEPARATE SHEET OF PAPER 27. SIGNATURE OF PERSON REPORTING DATE 28. DATE/HOUR ORAL CONTACT IN LDSS 29. REPORT TAKEN Yes No 30. NAME OF LDSS STAFF TO WHOM ORAL REPORT WAS MADE TEMPLATE VERSION OF DHR/SSA 180 (5/98) Previous editions are obsolete DISTRIBUTION: LDSS – Original and one copy STATES ATTORNEY – one copy (Child abuse only) REPORTER – one copy OFFICE OF STUDENT SERVICES – one copy