Edit AL DHR Child Abuse/Neglect Form Link
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SECTION I – CHILDREN ALLEGEDLY ABUSED OR NEGLECTED
Sr. No. Full Name Gender ETHNICITY DOB
1
2
3
4
5
Street Address
City
State
ZIP
Telephone
SECTION II – OTHER PERSONS LIVING WITH THE CHILDREN
(Include parents/custodians and other children in the home)
Sr. No. Full Name DOB ETHNICITY Relationship to the Children
1
2
3
4
5
SECTION III – PERSON(S) ALLEGEDLY RESPONSIBLE FOR THE ABUSE OR NEGLECT
Name
Gender
Ethnicity
BOD
Street Address
City
State
ZIP
Telephone
Name
Gender
Ethnicity
BOD
Street Address
City
State
ZIP
Telephone
SECTION IV – ABUSE OR NEGLECT ALLEGATIONS
(Describe what happened, how it affected the children, and the date(s) occurred, if known.)
Sr. No. Full Name DOB ETHNICITY Relationship to the Children
1
2
3
4
5
SECTION V - OTHER PERTINENT INFORMATION
SECTION VI - REPORTER
Name
Address
Telephone Number
Title / Agency / Relationship to Children
Did you verbally report the allegations to the Department of Human Resources or law enforcement?
FOR DHR USE ONLY
Country
Case #
Date
WRITTEN REPORT OF SUSPECTED CHILD ABUSE/NEGLECT
Date :
SECTION I – CHILDREN ALLEGEDLY ABUSED OR NEGLECTED
Name :
Gender :
Ethnicity :
DOB :
Address :
City :
State :
Zip :
Phone :
SECTION II – OTHER PERSONS LIVING WITH THE CHILDREN
Name :
DOB :
Ethnicity :
Realtionsip to Children :
SECTION III – PERSON(S) ALLEGEDLY RESPONSIBLE FOR THE ABUSE OR NEGLECT
Name :
Gender :
Ethnicity :
DOB :
Address :
City :
State :
Zip :
Phone :
Realtionsip to Children Allegedly Abused/Neglected :
SECTION IV – ABUSE OR NEGLECT ALLEGATIONS
Detail :
Did you see the abuse or neglect when it occurred? : No
Name :
Address :
Phone :
Realtionsip to Children Allegedly Abused/Neglected :
SECTION V - OTHER PERTINENT INFORMATION
Detail :
SECTION VI - REPORTER
Name :
Address :
Phone :
Realtionsip to Children Allegedly Abused/Neglected :
Did you verbally report the allegations to the Department of Human Resources or law enforcement? : Yes
Name :
Name of County DHR, Police Department, or Sheriff’s Department :
Date Reported :
FOR HDR USE ONLY
County :
Case # :
Date Report Received :