Fillable CHILD PROTECTION REPORT NICOLLET COUNTY HEALTH & HUMAN (Minnesota Department of Revenue)

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CHILD PROTECTION REPORT NICOLLET COUNTY HEALTH & HUMAN (Minnesota Department of Revenue)

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CHILD PROTECTION REPORT
NICOLLET COUNTY HEALTH & HUMAN SERVICES
St Peter Office
622 South Front Street | St Peter MN 56082
Phone: (507) 934-8559 | Fax: (507) 934-8552
North Mankato Office
2070 Howard Drive | North Mankato MN 56003
Phone: (507) 386-4528 | Fax: (507) 934-8552
REPORTER
Name
Mandated Reporter
☐YES
Address
Profession
Phone
Is Reporter a Licensed Day Care or Foster Care Provider?
☐YES
☐NO
Is Alleged Offender a Licensed Day Care or Foster Care Provider?
☐YES
☐NO
Is maltreatment alleged to have occurred in a Licensed Day Care or Foster Care
Home or Facility?
☐YES
☐NO
ALLEGED OFFENDER
Name
Address
Phone
Social Security Number
Date of Birth
Place of Employment
Phone
Relationship to Family
Access to Alleged Victim
ALLEGED VICTIM
Name
Age
DOB
Gender
☐Female
☐
Male
Address
Phone
Social Security Number
School
Mother
Social Security Number
Employer
Phone
Address & Phone (if
different from above)
Father
Social Security Number
Employer
Phone
Address & Phone (if
different from above)
Other Children in Household
Age
DOB
Gender
School
☐
Female
☐
Male
☐
Female
☐
Male
☐
Female
☐
Male
☐
Female
☐
Male
☐
Female
☐
Male
Summary of Report: (Include when and where incident occurred, observable injury, etc.) If Further
space is required, Please attach additional sheets.
History of Concerns:
Other Witnesses:
Name
Address
Phone
Name
Address
Phone
Parents aware of Report:
☐
YES
☐
NO
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CHILD PROTECTION REPORT NICOLLET COUNTY HEALTH & HUMAN (Minnesota Department of Revenue)

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Completed 21 July 2020

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