State of Illinois
Department of Children and Family Services
WRITTEN CONFIRMATION OF SUSPECTED CHILD ABUSE/NEGLECT REPORT:
Child’s Name Child’s Birth Date
If you are reporting more than one child from the same family please list their names and birth date in the space provided on
the reverse side of this form.
Street Address City Zip Code
Address (if different than the child’s address)
This is to confirm my oral report of , , made in accordance with the
Abused and Neglected Child reporting Act (325 ILCS 5 et seq). Please answer the following questions. (If you need more space, use
the back of this page.)
1. What injuries or signs of abuse/neglect are there?
2. How and approximately when did the abuse/neglect occur and how did you become aware of the abuse/neglect?
3. Had there been evidence of abuse/neglect before now? Yes No
4. If the answer to question 3 is “yes,” please explain the nature of the abuse/neglect.
5. Names and addresses of other persons who may be willing to provide information about this case.
6. Your relationship to child(ren)
7. Reporter Action Recommended or Taken:
PLEASE CHECK THE APPROPRIATE RESPONSE:
I saw the child(ren)
I heard about the child(ren) From whom?
have have not told the child’s family of my concern and of my report to the Department.
willing NOT willing to tell the child’s family of my concern and of my report to the Department.
believe do NOT believe the child is in immediate physical danger.
(Name Printed) (Signature)
INSTRUCTIONS ON REVERSE SIDE