Suspected Child Abuse Reporting Form printable pdf download

Iowa Department of Human Services

SUSPECTED CHILD ABUSE REPORTING FORM

This form may be used as the written report which the law requires all mandated reporters to file with the

Department of Human Services, following an oral report of suspected child abuse. Fill in as much information

under each category as is known. Submit the completed form to the Centralized Intake Unit, PO Box 4826, Des

Moines, Iowa 50305 within 24 hours of the oral report. (DHS hotline: 1-800-362-2178)

FAMILY INFORMATION

Name of child: ____________________________________ Age: _____________ Date of Birth: _____________

Address: _____________________________________________________________________________________

Phone: ____________________________ School:____________________________ Grade Level: ____________

Name of Parent

Phone (if different

or Guardian: ______________________________________________

from child’s): _________________

Address (if different from child’s): _________________________________________________________________

Other Children in the Home:

NAME

BIRTHDATE

CONDITION

INFORMATION ABOUT SUSPECTED ABUSE: In this section, indicate the date of suspected abuse; the nature,

extent and cause of the suspected abuse; the person(s) thought to be responsible for the suspected abuse;

evidence of previous abuse; and other pertinent information needed to conduct the investigation. Use the back of

this form if necessary to complete the information requested above and to identify individuals who have been

informed of the child abuse report, such as building administrator, supervisor, etc.

_____________________________________________________________________________________________

REPORTER INFORMATION:

Name and Title or Position: ______________________________________________________________________

Office Address: ________________________________________________________________________________

Phone: ________________________ Relationship to Child: ___________________________________________

Name(s) of other mandatory reporter(s) who has/have knowledge of the abuse: ___________________________

Date Suspected Abuse Occurred: ________________ Date Suspected Abuse Report Phoned in: ______________

Date Suspected Abuse Report Mailed: ____________ Name of DHS Worker Called: ________________________

Verbal Response from DHS Worker: _______________Accepted

_______________ Not Accepted

If the oral report form was not accepted for investigation, this form is not necessary.

Signature of Reporter

Date

HS5053 revised 8/13

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Suspected Child Abuse Reporting Form