Dcf 136 Form PDF Details

In an era where child welfare is of paramount importance, the DCF-136 form emerges as a critical tool in the fight against child abuse and neglect. This form, intended for use within the state of Connecticut, serves as a written report that follows an oral alert made through the Department of Children and Families (DCF) Careline. It is designated for mandated reporters—individuals who, due to their professional capacity, are legally required to report any suspicions of child maltreatment. As a comprehensive document, the DCF-136 form captures vital information about the child in question, including their name, age, race, and address, alongside the details of the suspected abuser and the nature of the suspected abuse or neglect. It also provides space for the reporter to describe the circumstances that led to the recognition of potential abuse or neglect, often detailing the evidence or observations that raised concern. The procedural aspect dictates that the form must be submitted within 48 hours following the initial oral report, ensuring a prompt response to protect the child's welfare. Accompanying this requirement, the form outlines the legal framework supporting child protection in Connecticut, emphasizing the state's commitment to safeguarding children from harm, promoting family integrity, and securing a safe environment for those at risk. Through its structured format and detailed content, the DCF-136 form not only facilitates the reporting process but also underlines the collective responsibility and legal obligations of individuals and entities in identifying and responding to child abuse and neglect.

QuestionAnswer
Form NameDcf 136 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdcf, dcf form 136, dcf ct 136 form, ct dcf 136

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REPORT OF SUSPECTED CHILD ABUSE OR NEGLECT

 

 

 

 

DCF-136

 

Careline

 

 

05/2015 (Rev.)

 

 

 

 

1-800-842-2288

 

 

 

 

 

 

 

 

 

 

Within forty-eight hours of making an oral report, a mandated reporter shall submit this form (DCF-136) to the relevant Area Office listed below

See the reverse side of this form for a summary of Connecticut law concerning the protection of children.

Please Print or Type

Child’s Name

M

Age Or DOB

Race:

☐ American Indian or Alaskan Native

☐ Hispanic

 

☐ F

 

 

☐ Asian/Pacific Islander

☐ White (not of Hispanic origin)

 

 

 

 

☐ Black/African American (not of

☐ Unknown

 

 

 

 

Hispanic Origin)

☐ Other:

Child’s Address

 

 

 

 

 

 

 

Name Of Parents Or Other Person Responsible For Child’s Care

Address

 

Phone Number

 

 

 

 

Name Of Careline Worker To Whom Oral Report Was Made

Date Of Oral Report

Date And Time Of Suspected Abuse/Neglect

 

 

 

 

Name Of Suspected Perpetrator, If Known

Address And Phone Number, If Known

 

Relationship To Child

 

 

 

 

Nature And Extent Of Injury(ies), Maltreatment Or Neglect

 

 

 

Describe The Circumstances Under Which The Injury(ies), Maltreatment Or Neglect Came To Be Known

Describe the Reasons Such Persons(s) Are Suspected of Causing Such Injuries, Maltreatment of Neglect

Information Concerning Any Previous Injury(ies), Maltreatment Or Neglect Of The Child Or His/Her Siblings

Information Concerning Any Prior Cases(s) In Which The Person(s) Have Been Suspected Of Causing An Injury(ies), Maltreatment Or Neglect Of A Child

List Names And Ages Of Siblings, If Known

What Action, If Any, Has Been Taken To Treat, Provide Shelter Or Otherwise Assist The Child?

REPORTER SECTION

Reporter’s Name:

Agency Name:

Phone Number:

Agency Address:

City:

Reporter’s Signature

Reporter’s Race

American Indian or Alaskan Native

Asian/Pacific Islander

Black/African American (not of Hispanic Origin)

Hispanic (any race)

White (not of Hispanic origin)

Prefer Not to Answer

Other:

Position

Date

 

 

WHITE COPY: TO DCF AREA OFFICE (SEE BELOW) IF YOU NEED ADDITIONAL SPACE, YOU MAY ATTACH MORE DOCUMENTATION

Bridgeport

Danbury

Hartford

Manchester

Norwalk

100 Fairfield Avenue

131 West Street

250 Hamilton Street

364 West Middle Turnpike

761 Main Avenue, I-Park Complex

Bridgeport, CT 06604

Danbury, CT 06810

Hartford, CT 06106

Manchester, CT 06040

Norwalk, CT 06851

203-384-5300

203-207-5100

860-418-8000

860-533-3600

203-899-1400

TDD: 203-384-5399

TDD: 203-748-8325

TDD: 800-315-4082

TDD: 800-315-4415

TDD: 203-899-1491

Fax: 203-384-5306

Fax: 203-207-5169

Fax: 860-418-8325

Fax: 860-533-3734

Fax: 203-899-1463, 203-899-1464

Meriden

Middletown

Milford

New Britain

New Haven

One West Main Street

2081 South Main Street

38 Wellington Road

One Grove Street, 4th Floor

One Long Wharf Drive

Meriden CT 06451

Middletown, CT 06457

Milford, CT 06461

New Britain, CT 06053

New Haven, CT 06511

203-238-8400

860-638-2100

203-306-5300

860-832-5200

203-786-0500

TDD: 203-238-8517

TDD: 860-638-2195

TDD: 203-306-5604

TDD: 860-832-5370

TDD: 203-786-2599

Fax: 203-238-6425

Fax: 860-346-0098

Fax: 203-306-5606

Fax: 860-832-5491

Fax: 203-786-0660

Norwich

Torrington

Waterbury

Willimantic

Special Investigations Unit

Two Courthouse Square

62 Commercial Blvd

395 West Main Street

322 Main Street

505 Hudson Street, 7th Floor

Norwich, CT 06360

Torrington, CT 06790

Waterbury, CT 06702

Willimantic, CT 06226

Hartford, CT 06106

860-886-2641

860-496-5700

203-759-7000

860-450-2000

860-550-6696

TDD: 860-885-2438

TDD: 860-496-5798

TDD: 203-465-7329

TDD: 860-456-6603

FAX: 860-723-7237

Fax: 860-887- 3683

Fax: 860-496-5834

Fax: 203-759-7295

Fax: 860-450-1051

 

SUMMARY OF LEGAL REQUIREMENTS CONCERNING CHILD ABUSE/ NEGLECT

PUBLIC POLICY OF THE STATE OF CONNECTICUT (C.G.S. §17a-101)

To protect children whose health and welfare may be adversely affected through injury and neglect; to strengthen the family and to make the home safe for children by enhancing the parental capacity for good child care; to provide a temporary or permanent nurturing and safe environment for children when necessary; and for these purposes to require the reporting of suspected child abuse or neglect, investigation of such reports by a social agency, and provision of services, where needed, to such child and family.

WHO IS MANDATED TO REPORT CHILD ABUSE/NEGLECT?

Child Advocate and OCA Employees

Mental Health Professionals

Chiropractors

Optometrists

Coaches and Directors of a Private Youth Sports,

Persons Paid to Care for Children

Organization or Team

Persons who Provide Services to

Coaches and Athletic Directors of Youth Athletics

and have Regular Contact with

Dental Hygienists

Students

Dentists

Pharmacists

Department of Children and Families Employees

Physical Therapists

Domestic Violence Counselors

Physician Assistants

Office of Early Childhood Employees and Department

Podiatrists

of Public health Employees who are Responsible

Police Officers

for Licensing Day Cares and Camps

Probation Officers (Juvenile or Adult)

Family Relations Counselors (Judicial Dept.)

Psychologists

Family Rel. Counselor Trainees (Judicial Dept.)

Public or Private Institution of Higher

Family Services Supervisors (Judicial Dept.)

Education Administrators, Faculty,

Licensed Foster Parents

Staff, Athletic Directors, Athletic

Licensed Marital and Family Therapists

Coaches and Athletic Trainers

Licensed or Unlicensed Interns at Any Hospital

Registered Nurses

Licensed or Unlicensed Resident Physicians

School Administrators

Licensed Physicians

School Coaches

Licensed Practical Nurses

School Guidance Counselors

Licensed Professional Counselors

School Paraprofessionals

Licensed Surgeons

School Superintendents

Licensed/Certified Alcohol and Drug Counselors

School Teachers

Licensed/Certified Emergency Medical Services Providers

Sexual Assault Counselors

Medical Examiners

Social Workers

Members of the Clergy

Substitute Teachers

DO THOSE MANDATED TO REPORT INCUR LIABILITY?

No. Any person, institution or agency which, in good faith, makes or does not make a report, shall be immune from any civil or criminal liability provided such person did not perpetrate or cause such abuse or neglect.

IS THERE A PENALTY FOR NOT REPORTING?

Yes. Any person required to report who fails to do so may be prosecuted for a Class A misdemeanor and may be required to participate in an educational and training program. Any person who intentionally and unreasonably interferes with or prevents a report may be prosecuted for a Class D felony.

IS THERE A PENALTY FOR MAKING A FALSE REPORT?

Yes. Any person who knowingly makes a false report of child abuse or neglect may be fined not more than $2,000 or imprisoned for not more than one year or both. The identity of such person shall be disclosed to the appropriate law enforcement agency and to the alleged perpetrator of the abuse.

WHAT ARE THE REPORTING REQUIREMENTS?

An oral report shall be made by a mandated reporter by telephone or in person to the DCF Careline or to a law enforcement agency as soon as practicable, but not later than 12 hours after the mandated reporter has reasonable cause to suspect or believe that a child has been abused or neglected or placed in imminent risk of serious harm. If a law enforcement agency receives an oral report, it shall immediately notify Careline. Oral reports to the Careline shall be recorded.

Within 48 hours of making an oral report, a mandated reporter shall submit a written report to the DCF Careline on the DCF-136, "Report of Suspected Child Abuse or Neglect."

When a mandated reporter is a member of the staff of a public or private institution or facility that provides care for children or a public or private school, the reporter shall also submit a copy of the written report to the person in charge of such institution, school or facility or the person's designee.

DCF CHILD ABUSE AND NEGLECT CARELINE: 1-800-842-2288

STATUTORY REFERENCES: C.G.S.17a-28, §17a-101 et seq.; §46b-120

DEFINITIONS OF ABUSE AND NEGLECT

Abused Child: Any child who has a non-accidental physical injury, or injuries which are at variance with the history given of such injuries, or is in a condition which is the result of maltreatment such as, but not limited to, malnutrition, sexual molestation, deprivation of necessities, emotional maltreatment or cruel punishment.

Neglected Child: Any child who has been abandoned or is being denied proper care and attention, physically, educationally, emotionally, or morally or is being permitted to live under conditions, circumstances or associations injurious to his or her well-being.

Exception: The treatment of any child by an accredited Christian Science practitioner shall not by itself constitute neglect or maltreatment.

CHILD UNDER AGE 13 WITH VENEREAL DISEASE: A physician or facility must report to Careline upon the consultation, examination or treatment for venereal disease of any child who has not reached his or her 13th birthday.

DO PRIVATE CITIZENS HAVE A RESPONSIBILITY FOR REPORTING?

Yes. Any person having reasonable cause to suspect or believe that any child under the age of 18 is in danger of being abused or has been abused or neglected may cause a written or oral report to be made to the Careline or a law enforcement agency. Any person making the report in good faith is immune from any liability, civil or criminal. However, the person is subject to the penalty for making a false claim.

WHAT IS THE AUTHORITY AND RESPONSIBILITY OF THE DEPARTMENT OF CHILDREN AND FAMILIES (DCF)?

All child protective services in Connecticut are the responsibility of the Department of Children and Families.

Upon the receipt of a report of child abuse or neglect, the Careline shall cause the report to be classified, evaluated immediately and forwarded to the appropriate Area Office for the commencement of an investigation or for the provision of services within timelines specified by statute and policy.

If an investigation produces evidence of child abuse or neglect, DCF shall take such measures as it deems necessary to protect the child, and any other children similarly situated, including,

but not limited to, immediate notification to the appropriate law enforcement agency, and the removal of the child from his or her home with or without the parents’ consent consistent with

state law.

If DCF has probable cause to believe that the child or any other child in the household is at

imminent risk of physical harm from the surroundings, and that immediate removal from such surroundings is necessary to ensure the child’s safety, the Commissioner or designee shall

authorize any employee of DCF or any law enforcement officer to remove the child and any other child similarly situated from such surroundings without the consent of the child’s parent or

guardian. The removal of a child shall not exceed 96 hours. If the child is not returned home within such 96-hour period, with or without protective services, DCF shall file a motion for temporary custody with the Superior Court for Juvenile Matters.

WHAT MEANS ARE AVAILABLE FOR REMOVING A CHILD FROM HIS OR HER HOME?

96-Hour hold by the Commissioner of DCF or designee (see above).

96-Hour hold by a physician – Any physician examining a child with respect to whom abuse or neglect is suspected shall have the right to keep such child in the custody of a hospital for no longer than 96 hours in order to perform diagnostic tests and procedures necessary

to the detection of child abuse or neglect and to provide necessary medical care with or without the consent of such child’s parents or guardian or other person responsible for the child’s care, provided the physician has made reasonable attempts to (1) advise such child’s parents or guardian or other person responsible for the child’s care that the physician suspects the child has been abused or neglected, and (2) obtain consent of such child’s parents or guardian or other person responsible for the child’s care. In addition, such

physician may take or cause to be taken photographs of the area of trauma visible on a child who is the subject of such report without the consent of such child’s parent’s or guardian or other person responsible for the child’s care. All such photographs or copies thereof shall be sent to the local police department and the Department of Children and Families.

Bench order of temporary custody – Whenever any person is arrested and charged with an offense under Section 53-20 or 53-21 or under Part V, VI, or VII of Chapter 952, as

amended, the victim of which offense was a minor residing with the defendant, any judge of the Superior Court may, if it appears that the child’s condition or circumstances surrounding the case so require, issue an order to the Commissioner of the Department of Children and Families to assume immediate custody of such child and, if the circumstances so require, any other children residing with the defendant and to proceed thereon as in other cases.

WHAT IS THE CENTRAL REGISTRY OF PERPETRATORS OF ABUSE OR NEGLECT? The Department of Children and Families maintains a registry of persons who have been substantiated as responsible for child abuse or neglect and pose a risk to the health safety or well-being of children. The Central Registry is available on a 24-hour daily basis to prevent or discover child abuse of children.

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