Report of Actual or Suspected Child Abuse or Neglect

Submit this form to the local County DHS office immediately after completion. You may also reach them via fax at XX-XXXX-XXXX for faster processing. Always ensure to keep a copy of the submitted form for your records, and contact the office to confirm receipt.

Important dates related to this form will be announced on the Michigan Department of Human Services website as they become applicable. Keep an eye out for updates regarding any changes in reporting requirements or procedures. Ensure you are informed about any policy changes that may affect the filing process.

The purpose of this form is to facilitate the reporting of actual or suspected child abuse or neglect cases in Michigan. It is designed to collect all pertinent information necessary for authorities to investigate and take appropriate action. By using this form, individuals contribute to the safety and welfare of children at risk.

• 1. Date: Date the form is completed.
• 2. Children's List: List of child(ren) suspected of abuse or neglect.
• 3. Mother's Name: Enter the name of the child's mother.
• 4. Father's Name: Enter the name of the child's father.
• 5. Children's Address: Address of the child(ren) involved.
• 6. City: City where the child(ren) resides.
• 7. Social Security Number: Children's Social Security number.
• 8. Sex: Gender of the child.
• 9. Race: Ethnic background of the child.
• 10. County: County where the child lives.
• 11. Phone Number: Contact number for the child's residence.
• 12. Alleged Perpetrator: Name of the person suspected of abuse.
• 13. Living with: Persons living with the child when abuse occurred.
• 14. Relationship: Relationship of the alleged perpetrator to the child.
• 15. Abuse Address: Address where abuse occurred.
• 16. Description of Abuse: Details of observed injury or conditions.
• 17. Source of Referral: Professionals making the referral.
• 18. Referring Person's Name: Name of the individual making the report.
• 19. Referring Organization: Name of the organization reporting the incident.
• 20. Referring Address: Address of the referring organization.
• 21. City/State/Zip: City, State, and Zip code of the organization.
• 22. Summary Report: Summary of conclusions from a medical examination.
• 23. Laboratory Report: Details of any laboratory analysis.
• 24. X-Ray: Information regarding any X-Ray conducted.
• 25. Physical Signs: History or indication of past abuse.
• 26. Physician's Signature: Signature of the physician if applicable.

Failing to submit this form may delay the intervention needed to protect a child from abuse or neglect. It is essential that reports are processed in a timely manner to ensure the safety of affected children. Delayed action can lead to further harm and missed opportunities for support.

• Child Safety: The primary concern is the ongoing safety of the child who is suspected to be abused or neglected.
• Legal Implications: Failure to report can have legal ramifications for individuals who are mandated reporters.
• Support Services: Not submitting the form may impede access to critical support services for the child and family.

• 1. Reporting Suspicions: Utilized when there are reasonable suspicions of abuse or neglect.
• 2. Documenting Evidence: Provide a written account of observed signs or disclosures of abuse.
• 3. Mandatory Reporting: Required by law for certain professionals such as teachers and healthcare providers.