Fill - Free fillable Report of Suspected Child Abuse/ Child Neglect/Mental Injury PDF form

Report of Suspected Child Abuse/

Child Neglect/Mental Injury

Ellicott City, Maryland 21042

INSTRUCTIONS: Respond to each item even if reply is “unknown” or “none.” For suspected child abuse/neglect/mental

injury, an oral report must be made to the Howard County Department of Social Services (DSS) (Child Protective Services

410-872-4203 or Adult Protective Services 410-872-8823, as appropriate) or to the Department of Police 410-313-2200,

24 hours/7 days a week. This report must be ﬁled within 48 hours after making an oral report. Type or print ﬁrmly on a hard

surface. (See reverse side for deﬁnitions and additional instructions.)

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Name of person making report:

__________________________________________

Signature:

_________________________________

Position: _________________________________________________ School name:

______________________________________________

School phone: ____________________________________________

Check type(s) of referral (check all that apply): q Physical abuse q Sexual abuse q Neglect q Mental injury q Vulnerable adult

Name of child: _______________________________________________________ Sex:

M Birth date: ___/____/________

Address (where child may be seen):

_________________________________________________________________________________

Age: _________ Grade: ________ Race:

_______________________________________________________________________________

Name of person(s) responsible for child’s care (Parent/Guardian)

Father: ________________________________________________________________ Phone:

____________________________________

Mother: _______________________________________________________________ Phone:

__________________________________

Guardian: ______________________________________________________________ Phone:

_________________________________

Relationship of guardian, if any:

___________________________________________________________________________________

Address: _____________________________________________________________________________ Zip code:

_________________

Name of suspected abuser:

_______________________________________________

Phone:

____________________________________

Address:

________________________________________________________________________________________________________

Relationship (of suspected abuser) to child:

_________________________________________________________________________

State the nature and extent of the current injury to the child or the circumstances leading to the suspicion that the child

is a victim of abuse/neglect/mental injury:

Give information concerning previous injury or conditions of neglect to this child or other children in this family situation,

including previous action taken, if any:

State any other information available to you which would be of aid in establishing the cause of the injuries and/or neglect.

Oral report information

Date and hour of oral report: ___/____/________ _____________________________________ Date Mailed: ___/____/________

Name of agency representative to whom oral report was made: _______________________________________________________

Agency contacted: q DSS q Police Department

Copies (white) Department of Social Services (Canary) State’s Attorney (Pink) Coordinator, Pupil Support Services (Goldenrod) Principal’s Folder

Revised 3/19

DEFINITIONS OF CHILD ABUSE AND CHILD NEGLECT

A. CHILD - Any person under eighteen (18) years of age.

PHYSICAL ABUSE - Any physical injury, not necessarily visible, of a child or vulnerable adult, by any parent, adoptive

parent, family

or household member, school system employee, service provider, or other person who has permanent

or temporary care or custody or responsibility for supervision of the child or vulnerable adult, under circumstances

that indicate that the health or welfare of the child or vulnerable adult is harmed or at substantial risk of being harmed.

C. SEXUAL ABUSE - And sexual act or acts whether physical injuries are sustained or not involving sexual molestation or

exploitation, including but not limited to incest, rape, or sexual offense in any degree, sodomy or unnatural or

perverted sexual practices on a child or vulnerable adult by a parent, adoptive parent, family or household member,

school system employee, service provider, or other person who has the permanent or temporary care, custody, or

responsibility for supervision of a minor child or vulnerable adult. Sexual molestation or exploitation includes, but is

not limited to, contact or conduct with a child or vulnerable adult ranging from exposure, voyeurism, sexual advances,

kissing, or fondling to sexual crime in any degree, rape, sodomy, prostitution, or allowing, permitting, encouraging,

or encouraging a child or vulnerable adult in pornographic display, photographing, ﬁlming, or depiction of a child

or vulnerable adult as prohibited by law.

D. MENTAL INJURY - The observation, identiﬁable, and substantial impairment of a child’s or vulnerable adult’s mental or

psychological ability to function. A child suspected of being abused through mental injury need not be currently

receiving mental health services, but the level of impairment of the child’s ability to function must be sufﬁciently

severe and chronic to indicate a need for speciﬁc psychiatric, psychological or social work intervention.

E. VULNERABLE ADULT - Persons 18 years of age or older who are believed to lack the physical or mental capacity to

care for their daily needs.

(The indicators for Mental Injury, Physical Abuse, Neglect, and Sexual Abuse refer to all students under 18, as well as

“vulnerable adults” over the age of 18, who lack the capacity to care for themselves.)

ADDITIONAL INSTRUCTIONS FOR REPORTING CHILD ABUSE

1. An oral report of suspected child abuse must be made immediately during school hours. A written report must be

submitted within

48 hours. It is not necessary to observe outward signs of injury to the child. Neither is it necessary

for the reporter to establish proof

that abuse has occurred. Protection of the child is paramount. If abuse is suspected,

a report must be submitted.

2. Every health practitioner, educator, social worker, or law-enforcement ofﬁcer, who contacts, examines, attends, or

treats a child and who believes or has reason to believe that the child has been abused is required to make a report

to either the Howard County Department of Social Services (DSS) (Child Protective Services 410-872-4203 or Adult

Protective Services 410-872-8823, as appropriate) or the Department of Police 410-313-2200, 24 hours/7 days a week.

WHITE COPY

Howard County Department of Social Services

9780 Patuxent Woods Drive

Columbia, MD 21046

(Note; DSS will send copies to the Howard County Department of Police as appropriate in cases involving abuse.)

CANARY COPY

Howard County State’s Attorney Ofﬁce

District Court Multi-Service Center

3451 Court House Drive

Ellicott City, Maryland 21043

PINK COPY (Attach a copy of front page)

Pupil Support Services

10920 Clarksville Pike

Ellicott City, Maryland 21042

GOLDENROD COPY (Attach a copy of front page)

Principal’s Folder

School

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