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2. CARLTON COUNTY CHILD MALTREATMENT REPORT
4. Are you a Mandated Reporter?

   1. Yes
   2. No
6. Are you a Voluntary Reporter?

   1. Yes
   2. No
8. Have you made a verbal report to an Intake Worker?

   1. Yes
   2. No
10. *Mandated Reporters are required to submit a written report within 72 hours, excluding holidays and weekends. [minn-stat.260E.091a]
12. REPORTER INFORMATION
14. Reporter Name

    Anonymous - (please note mandated reporters may not choose to remain anonymous)

16. Agency/School of Reporter (if applicable)
18. Phone Number
20. Email
22. Relationship to Victim
24. Mandated Reporter Agency Mailing Address (if applicable)
26. Reporter Address: Street, City, State, Zip
28. IDENTIFYING INFORMATION OF ALLEGED VICTIM(S)
30. Child's Full Name
32. Child's Birthday or Age
33. Gender
    -- Select One --MaleFemaleOther
35. Child's Address: Street, City, State, Zip
37. Additional Children Information: Please identify other Children who reside in the home. List their dates of birth or ages and relationships to the Child Victim(s). Please identify if the child is an additional victim.
39. Do you know or have reason to believe that the Child/Children have American Indian/Tribal Hertage?

    1. Yes
    2. No
    3. Unknown
40. If Yes, please identify the Tribe the Child(ren) are associated with.
42. Parent/Guardian Name
43. Phone Number
45. Street Address, City, State, Zip
46. Date of Birth or Age
48. Parent/Guardian Name
49. Phone Number
51. Street Address, City, State, Zip
52. Date of Birth or Age
54. Family strengths/family support people/current services
56. Child vulnerability and/or current family stressors (behavioral concerns, medical diagnoses, mental health concerns, poverty, etc.)
58. Please identify any other adults who reside in the home. If you have knowledge of custody orders please share that here along with household information (address, people who reside in that home, contact information) if the child spends time in a different household
60. PERSON(S) BELIEVED TO BE RESPONSIBLE FOR THE ABUSE OR NEGLECT
62. Name
63. Phone
65. Street Address, City, State, Zip
67. Gender

    1. Female
    2. Male
69. If there is more than One Alleged Maltreater please identify them here:
71. INCIDENT REPORT
73. Please provide us all of the information and details about what you are reporting. Please include when the incident occurred, harm/injuries to the child(ren) and any other details that would be helpful in understanding what occurred.
75. Does the Person believed to be responsible for the abuse or neglect have access to the child(ren)?

    1. Yes
    2. No
    3. Unknown
77. Please be aware that you will be contacted for a verbal report to ensure we have all the information needed to make an appropriate screening decision.
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit Submit and Print

* indicates a required field