Report of Suspected Child Abuse/Child Neglect/Mental Injury  SY 2022-2023
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 at 410-313-2200, 24 hours/7 days a week  This report must be filed within 48 hours after making an oral report.
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Email *
Name of person making report: *
Your role/position in the HCPSS: *
Your phone number: *
Type of referral (check all that apply): * *
Required
Name of child: *
Child's gender: *
Child's Birth date:
MM
/
DD
/
YYYY
Address where child may be seen: *
Child's Age:
Child's Grade:
Child's Race: *
Name of person(s) responsible for child's care (Parent/Guardian):
Father's Name:
Father's Phone Number:
Mother's Name:
Mother's Phone Number:
Guardian's Name:
Guardian's Phone Number:
Relationship of guardian to child, if any:
Address of person responsible for child's care:
Name of suspected abuser:
Phone number of suspected abuser:
Address of suspected abuser:
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.
Are weapons in the home or  known to be  carried by the family or alleged maltreator? *
Is there a history of violence, drugs, mental illness or retaliation in the family?   *
If yes to either, describe in detail:
Waiver of Confidentiality:  I agree to waive my right to confidentiality as a mandated reporter. *
Date and Hour of Oral Report: *
Name of Representative to whom Oral Report was made: *
Agency Contracted: *
Required
School *
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This form was created inside of Howard County Public School System. Report Abuse