REPORT OF SUSPECTED CHILD ABUSE OR NEGLECT
DCF-136
05/2015 (Rev.)
Careline
1-800-842-2288
Within fort
y
-eight hours of making an oral report, a mandated reporter shall submit this form (DCF-136) to the relevant Area Office listed below
See the reverse side of this form for a summary of Connecticut law concerning the protection of children.
Please Print or Type
Child’s Name
M
F
A
ge Or DOB Race:
A
merican Indian or Alaskan Native
Asian/Pacific Islander
Black/African American (not of
Hispanic Origin)
Hispanic
White (not of Hispanic origin)
Unknown
Other ____________________
Child’s Address
Name Of Parents Or Other Person Responsible For Child’s Care
A
ddress
Phone Number
Name Of Careline Worker To Whom Oral Report Was Made Date Of Oral Report
Date And Time Of Suspected Abuse/Neglect
Name Of Suspected Perpetrator, If Known
A
ddress And
Phone Number, If Known
Relationship To Child
Nature
nd Extent Of Injury(ies), Maltreatment Or Neglect
Describe The Circumstances Under Which The Injury(ies), Maltreatment Or Neglect Came To Be Known
Describe the Reasons Such Persons(s) Are Suspected of Causing Such Injuries, Maltreatment of Neglect
Information Concerning Any Previous Injury(ies), Maltreatment Or Neglect Of The Child Or His/Her Siblings
Information Concerning
A
ny Prior Cases(s) In Which The Person(s) Have Been Suspected Of Causing An Injury(ies), Maltreatment Or Neglect Of A Child
List Names And Ages Of Siblings, If Known
What Action, If Any, Has Been Taken To Treat, Provide Shelter Or Otherwise Assist The Child?
REPORTER SECTION
Reporter’s Name:
Agency Name:
Phone Number:
Agency Address:
City:
Reporter’s Race
American Indian or Alaskan Native
Asian/Pacific Islander
Black/African American (not of Hispanic Origin)
Hispanic (any race)
White (not of Hispanic origin)
Prefer Not to Answer
Other ______________________________________
Reporter’s Signature Position
Date
WHITE COPY: TO DCF AREA OFFICE (see below) IF YOU NEED ADDITIONAL SPACE, YOU MAY ATTACH MORE DOCUMENTATION
Bridgeport
100 Fairfield Avenue
Bridgeport, CT 06604
203-384-5300
TDD: 203-384-5399
Fax: 203-384-5306
Danbu
r
y
131 West Street
Danbury, CT 06810
203-207-5100
TDD: 203-748-8325
Fax: 203-207-5169
Hartford
250 Hamilton Street
Hartford, CT 06106
860-418-8000
TDD: 800-315-4082
Fax: 860-418-8325
Mancheste
r
364 West Middle Turnpike
Manchester, CT 06040
860-533-3600
TDD: 800-315-4415
Fax: 860-533-3734
Norwalk
761 Main Avenue, I-Park Complex
Norwalk, CT 06851
203-899-1400
TDD: 203-899-1491
Fax: 203-899-1463, 203-899-1464
Meriden
One West Main Street
Meriden CT 06451
203-238-8400
TDD: 203-238-8517
Fax: 203-238-6425
Middletown
2081 South Main Street
Middletown, CT 06457
860-638-2100
TDD: 860-638-2195
Fax: 860-346-0098
Milford
38 Wellington Road
Milford, CT 06461
203-306-5300
TDD: 203-306-5604
Fax: 203-306-5606
New Britain
One Grove Street, 4th Floor
New Britain, CT 06053
860-832-5200
TDD: 860-832-5370
Fax: 860-832-5491
New Haven
One Long Wharf Drive
New Haven, CT 06511
203-786-0500
TDD: 203-786-2599
Fax: 203-786-0660
Norwich
Two Courthouse Square
Norwich, CT 06360
860-886-2641
TDD: 860-885-2438
Fax: 860-887- 3683
Torrington
62 Commercial Blvd
Torrington, CT 06790
860-496-5700
TDD: 860-496-5798
Fax: 860-496-5834
Waterbur
y
395 West Main Street
Waterbury, CT 06702
203-759-7000
TDD: 203-465-7329
Fax: 203-759-7295
Willimantic
322 Main Street
Willimantic, CT 06226
860-450-2000
TDD: 860-456-6603
Fax: 860-450-1051
Special Investigations Unit
505 Hudson Street, 7
th
Floor
Hartford, CT 06106
860-550-6696
FAX: 860-723-7237
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signature
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SUMMARY OF LEGAL REQUIREMENTS CONCERNING CHILD ABUSE/ NEGLECT
PUBLIC POLICY OF THE STATE OF CONNECTICUT (C.G.S. §17a-101)
To protect children whose health and welfare may be adversely affected
through injury and neglect; to strengthen the family and to make the home
safe for children by enhancing the parental capacity for good child care; to
provide a temporary or permanent nurturing and safe environment for
children when necessary; and for these purposes to require the reporting of
suspected child abuse or neglect, investigation of such reports by a social
agency, and provision of services, where needed, to such child and family.
WHO IS MANDATED TO REPORT CHILD ABUSE/NEGLECT?
Child Advocate and OCA Employees Mental Health Professionals
Chiropractors
Coaches and Directors of a Private Youth Sports,
Organization or Team
Optometrists
Persons Paid to Care for Children
Persons who Provide Services to
Coaches and Athletic Directors of Youth Athletics and have Regular Contact with
Dental Hygienists Students
Dentists
Pharmacists
Physical Therapists
Physician Assistants
Department of Children and Families Employees
Domestic Violence Counselors
Office of Early Childhood Employees and Department
of Public health Employees who are Responsible
for Licensing Day Cares and Camps
Podiatrists
Police Officers
Probation Officers (Juvenile or Adult)
Family Relations Counselors (Judicial Dept.) Psychologists
Family Rel. Counselor Trainees (Judicial Dept.)
Family Services Supervisors (Judicial Dept.)
Licensed Foster Parents
Licensed Marital and Family Therapists
Licensed or Unlicensed Interns at Any Hospital
Public or Private Institution of Higher
Education Administrators, Faculty,
Staff, Athletic Directors, Athletic
Coaches and Athletic Trainers
Registered Nurses
Licensed or Unlicensed Resident Physicians School Administrators
Licensed Physicians School Coaches
Licensed Practical Nurses
Licensed Professional Counselors
Licensed Surgeons
School Guidance Counselors
School Paraprofessionals
School Superintendents
Licensed/Certified Al
c
ohol and Drug Counselors School Teachers
Licensed/Certified Emergency Medical Services Providers
Sexual Assault Counselors
Medical Examiners Social Workers
Members of the Clergy Substitute Teachers
DO THOSE MANDATED TO REPORT INCUR LIABILITY?
No. Any person, institution or agency which, in good faith, makes or does not make a report,
shall be immune from any civil or criminal liability provided such person did not perpetrate or
cause such abuse or neglect.
IS THERE A PENALTY FOR NOT REPORTING?
Yes. Any person required to report who fails to do so may be prosecuted for a Class A
misdemeanor and may be required to participate in an educational and training program. Any
person who intentionally and unreasonably interferes with or prevents a report may be
prosecuted for a Class D felony.
IS THERE A PENALTY FOR MAKING A FALSE REPORT?
Yes. Any person who knowingly makes a false report of child abuse or neglect may be fined
not more than $2,000 or imprisoned for not more than one year or both. The identity of such
person shall be disclosed to the appropriate law enforcement agency and to the alleged
perpetrator of the abuse.
WHAT ARE THE REPORTING REQUIREMENTS?
An oral report shall be made by a mandated reporter by telephone or in person to the DCF
Careline or to a law enforcement agency as soon as practicable, but not later than 12
hours after the mandated reporter has reasonable cause to suspect or believe that a child
has been abused or neglected or placed in imminent risk of serious harm. If a law
enforcement agency receives an oral report, it shall immediately notify Careline. Oral
reports to the Careline shall be recorded.
Within 48 hours of making an oral report, a mandated reporter shall submit a written report
to the DCF Careline on the DCF-136, "Report of Suspected Child Abuse or Neglect."
When a mandated reporter is a member of the staff of a public or private institution or
facility that provides care for children or a public or private school, the reporter shall also
submit a copy of the written report to the person in charge of such institution, school or
facility or the person's designee.
DCF CHILD ABUSE AND NEGLECT CARELINE: 1-800-842-2288
STATUTORY REFERENCES: C.G.S.17a-28, §17a-101 et seq.; §46b-120
DEFINITIONS OF ABUSE AND NEGLECT
Abused Child: Any child who has a non-accidental physical injury, or injuries which are at
variance with the history given of such injuries, or is in a condition which is the result of
maltreatment such as, but not limited to, malnutrition, sexual molestation, deprivation of
necessities, emotional maltreatment or cruel punishment.
Neglected Child: Any child who has been abandoned or is being denied proper care and
attention, physically, educationally, emotionally, or morally or is being permitted to live under
conditions, circumstances or associations injurious to his or her well-being.
Exception: The treatment of any child by an accredited Christian Science practitioner shall
not by itself constitute neglect or maltreatment.
CHILD UNDER AGE 13 WITH VENEREAL DISEASE: A physician or facility must report to
Careline upon the consultation, examination or treatment for venereal disease of any child who
has not reached his or her 13
th
birthday.
DO PRIVATE CITIZENS HAVE A RESPONSIBILITY FOR REPORTING?
Yes. Any person having reasonable cause to suspect or believe that any child under the age
of 18 is in danger of being abused or has been abused or neglected may cause a written or
oral report to be made to the Careline or a law enforcement agency. Any person making the
report in good faith is immune from any liability, civil or criminal. However, the person is
subject to the penalty for making a false claim.
WHAT IS THE AUTHORITY AND RESPONSIBILITY OF THE DEPARTMENT OF CHILDREN
AND FAMILIES (DCF)?
All child protective services in Connecticut are the responsibility of the Department of Children
and Families.
Upon the receipt of a report of child abuse or neglect, the Careline shall cause the report to be
classified, evaluated immediately and forwarded to the appropriate Area Office for the
commencement of an investigation or for the provision of services within timelines specified by
statute and policy.
If an investigation produces evidence of child abuse or neglect, DCF shall take such measures
as it deems necessary to protect the child, and any other children similarly situated, including,
but not limited to, immediate notification to the appropriate law enforcement agency, and the
removal of the child from his or her home with or without the parents’ consent consistent with
state law.
If DCF has probable cause to believe that the child or any other child in the household is at
imminent risk of physical harm from the surroundings, and that immediate removal from such
surroundings is necessary to ensure the child’s safety, the Commissioner or designee shall
authorize any employee of DCF or any law enforcement officer to remove the child and any
other child similarly situated from such surroundings without the consent of the child’s parent
or guardian. The removal of a child shall not exceed 96 hours. If the child is not returned
home within such 96-hour period, with or without protective services, DCF shall file a motion
for temporary custody with the Superior Court for Juvenile Matters.
WHAT MEANS ARE AVAILABLE FOR REMOVING A CHILD FROM HIS OR HER HOME?
96-Hour hold by the Commissioner of DCF or designee (see above).
96-Hour hold by a physician – Any physician examining a child with respect to whom
abuse or neglect is suspected shall have the right to keep such child in the custody of a
hospital for no longer than 96 hours in order to perform diagnostic tests and procedures
necessary to the detection of child abuse or neglect and to provide necessary medical
care with or without the consent of such child’s parents or guardian or other person
responsible for the child’s care, provided the physician has made reasonable attempts to
(1) advise such child’s parents or guardian or other person responsible for the child’s care
that the physician suspects the child has been abused or neglected, and (2) obtain
consent of such child’s parents or guardian or other person responsible for the child’s
care. In addition, such physician may take or cause to be taken photographs of the area
of trauma visible on a child who is the subject of such report without the consent of such
child’s parent’s or guardian or other person responsible for the child’s care. All such
photographs or copies thereof shall be sent to the local police department and the
Department of Children and Families.
Bench order of temporary custody – Whenever any person is arrested and charged with
an offense under Section 53-20 or 53-21 or under Part V, VI, or VII of Chapter 952, as
amended, the victim of which offense was a minor residing with the defendant, any judge
of the Superior Court may, if it appears that the child’s condition or circumstances
surrounding the case so require, issue an order to the Commissioner of the Department of
Children and Families to assume immediate custody of such child and, if the
circumstances so require, any other children residing with the defendant and to proceed
thereon as in other cases.
WHAT IS THE CENTRAL REGISTRY OF PERPETRATORS OF ABUSE OR NEGLECT?
The Department of Children and Families maintains a registry of persons who have been
substantiated as responsible for child abuse or neglect and pose a risk to the health safety or
well-being of children. The Central Registry is available on a 24-hour daily basis to prevent or
discover child abuse of children.