DEMO FORM - Clone of NYS Office of Children and Family Services REPORT OF SUSPECTED CHILD ABUSE OR MALTREATMENT

NYS Office of Children and Family Services

REPORT OF SUSPECTED CHILD ABUSE OR MALTREATMENT
Report Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Type a question
AM/PM*

AMPM
SUBJECTS OF REPORT

List all children in household, adults responsible and alleged subjects.
How many people do you want to list on the report
More than 7 subjects of report

YesNo
You can only enter 7 people directly on the report. Feel free to add details of any other people in the continuation box for the explanation at the end.

Person #1
Name*

First NameLast Name
Aliases
Sex*
Sex Code
Birthday

MonthDayYear
Date
Age
Estimate ONLY if birthday is unknown
Race*
Race Code
Is this person hispanic/latino?*

YesNo
Relation*
Relation Code
Role*
Role Code
Language*
Language Code

Person #2
Name*

First NameLast Name
Aliases
Sex*
Sex Code
Birthday

MonthDayYear
Date
Age
Estimate ONLY if birthday is unknown
Race*
Race Code
Is this person hispanic/latino?*

YesNo
Relation*
Relation Code
Role*
Role Code
Language*
Language Code

Person #3
Name*

First NameLast Name
Aliases
Sex*
Sex Code
Birthday

MonthDayYear
Date
Age
Estimate ONLY if birthday is unknown
Race*
Race Code
Is this person hispanic/latino?*

YesNo
Relation*
Relation Code
Role*
Role Code
Language*
Language Code

Contact Info Section
Contact Information

List addresses and telephone numbers (using line numbers from above)
For reference when filling out the below items use these numbers to identify which people they apply to:
1. {name73} ({birthday}{age} / {sex})
2. {name95} ({birthday99}{age100} / {sex97})
3. {name111} ({birthday115}{age116} / {sex113})
4. -
5. -
6. -
7. -
Which people above does the following address #1 apply to?

1234567
Address #1 People
Address #1

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number #1
Please enter a valid phone number.
Which people above does the following address / phone #2 apply to?

1234567
Address #2 People
Address #2

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number #2
Please enter a valid phone number.
Which people above does the following address / phone #3 apply to?

1234567
Address #3 People
Address #3

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number #3
Please enter a valid phone number.
Basis of Suspicions

Alleged suspicions of abuse or maltreatment. For each item below select the child(ren)'s number(s) that it applies to. If all children, Select "ALL".
For reference when filling out the below items use these numbers to identify which child(ren) they apply to:
1. {name73} ({birthday}{age} / {sex})
2. {name95} ({birthday99}{age100} / {sex97})
3. {name111} ({birthday115}{age116} / {sex113})
4. -
5. -
6. -
7. -
DOA/Fatality

1234567ALL
DOA/Fatality #s
Fractures

1234567ALL
Fractures #s
Internal injuries (e.g., subdural hematoma)

1234567ALL
Internal injuries (e.g., subdural hematoma) #s
Lacerations/bruises/welts

1234567ALL
Lacerations/bruises/welts #s
Other (specify)

1234567ALL
Other (specify) #s
Other*
Briefly specify other finding
Date/Time of Alleged Incident (If known)

MonthDayYear
Hour Minutes
State reasons for suspicion, including the nature and extent of each child's injuries, abuse or maltreatment, past and present, and any evidence or suspicions of "Parental" behavior contributing to the problem.*
If you need more space use the continuation box below
CONTINUED: State reasons for suspicion, including the nature and extent of each child's injuries, abuse or maltreatment, past and present, and any evidence or suspicions of "Parental" behavior contributing to the problem.
You can also put details of additional people in this section.
Additional Sheet Attached?

Yes
The Mandated Reporter Requests Finding of Investigation?*

YesNo
Crew #1 Name*
Title*
Signature*

Clear
Crew #2 Name
Date Report Submitted*

MonthDayYear
Date
Case ID (NOT the CAD #)*
Provided by the NYS Register when you call in with the report
Call ID (NOT the CAD #) *
Provided by the NYS Register when you call in with the report
Local Case # (NOT the CAD #)
Provided by the NYS Register when you call in with the report
LOCAL DIST/AGENCY*
Provided by the NYS Register when you call in with the report
Should be Empty:

SUBJECTS OF REPORT

Contact Information

Basis of Suspicions