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Step One

GENERAL INFORMATION
MN Statutes Section 260E.06, Subd. 1(a). A person who knows or has reason to believe a child is being maltreated, as defined in section 260E.03, or has been maltreated within the preceding three years shall immediately report the information to the local welfare agency, agency responsible for assessing or investigating the report.
In accordance with M.S. 626.556, the name of the person or agency reporting child abuse or neglect shall not be disclosed to the subject of the report while the report is under assessment. Upon completion of the assessment, the name of the reporting party shall be confidential and shall be disclosed only upon court order.
IF YOU FEEL THIS CHILD(REN) IS IN IMMEDIATE DANGER, PLEASE CALL 911. If you are unsure and/or would prefer to speak to a Child Protection social worker, please call Meeker County Health and Human Services at 320-693-5300 and a social worker will assist you with your report.
Date and time of report:
Date and time of report:
Date and time of report:
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REPORTER INFORMATION

Reporter Full Name (First, Middle Initial, Last)
Phone Number:
Email Address:
Address1
Address2
City
State
Zip
Mandated Reporter?
1. Yes
2. No
Click the link below to see if you are mandated:
Mandated reporter resources / Minnesota Department of Human Services
If yes, did you make an oral report?
1. Yes
2. No
Reporter Agency/School Name:
Has anyone else been notified of this report (law enforcement, child, parent, etc.)?
1. Yes
2. No
Would you like to be notified of the outcome of the report (you must provide email or address above)?
1. Yes
2. No
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CHILDREN IN THE HOME/ALLEGED VICTIM

ALLEGED OFFENDER

Name:
Relation to Alleged Victim:
Gender Assigned at Birth:
1. Male
2. Female
Race:
Is reporter aware of any Native American descent?
1. Yes
2. No
Language:
DOB or Approximate Age:
Phone:
Address1
Address2
City
State
Zip
Custody/Living Arrangement:
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FAMILY OF ALLEGED VICTIM

Parent/Guardian 1 Name:
Relation to Alleged Victim:
Gender Assigned at Birth:
1. Male
2. Female
Race:
Is reporter aware of any Native American descent?
1. Yes
2. No
If yes, are you aware of what tribe?
Language:
DOB or Approximate Age:
Phone:
Address1
Address2
City
State
Zip
Parent/Guardian 2 Name:
Relation to Alleged Victim:
Gender Assigned at Birth:
1. Male
2. Female
Race:
Is reporter aware of any Native American descent?
1. Yes
2. No
If yes, are you aware of what tribe?
Language:
DOB or Approximate Age:
Phone:
Address1
Address2
City
State
Zip
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OTHER ADULTS IN THE HOME

Name:
Relation to Alleged Victim:
Gender Assigned at Birth:
1. Male
2. Female
Race:
Is reporter aware of any Native American descent?
1. Yes
2. No
If yes, are you aware of what tribe?
Language:
DOB or Approximate Age:
Phone:
Address1
Address2
City
State
Zip
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MALTREATMENT

What is your current concern?
Estimated Date/Date Span of Maltreatment?
Estimated Date/Date Span of Maltreatment? Start Date
—
Estimated Date/Date Span of Maltreatment? End Date
In the box below, please describe the nature and extent of the current maltreatment/abuse/neglect, including conditions, dates, and description of injury. What was seen, heard and when the incident occurred as well as who was present. Additionally, include any statements made by the child or anyone else who was present. Attach pictures if applicable (at the end of the form).
What impact has this had on the child(ren)?
How do you know this information?
Is the child(ren) in any immediate/present danger?
1. Yes
2. No
How long has this been going on?
How long has this been going on? Start Date
—
How long has this been going on? End Date
Please provide any additional information such as: information concerning any previous abuse/neglect to this child(ren), as well as any action taken, or any other information you wish to share that you think would be helpful in assessing this situation.
FILE UPLOAD
Please attach any pictures or other documents to support this report.
I have additional information-please contact me.
1. Yes
TO THE REPORTER
In accordance with MN Statute 626.556, the name of the person or agency reporting child abuse or neglect shall not be disclosed to the subject of the report while the report is under assessment. Upon completion of the assessment, the name of the reporting party shall be confidential and shall be disclosed only upon court order.
If you would like a copy of this emailed to you, enter your email address below or option to print after submitting the form.
SIGN AND SUBMIT
Print Name:
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature*
Date Signed:
Date Signed:

Leave This Blank:

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

This field is not part of the form submission.
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CHILD PROTECTION REPORT FORM

Steps

Step One

REPORTER INFORMATION

CHILDREN IN THE HOME/ALLEGED VICTIM

ALLEGED OFFENDER

FAMILY OF ALLEGED VICTIM

OTHER ADULTS IN THE HOME

MALTREATMENT

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