Form DCF-136 at a glance
What it is: The DCF-136 05/2015 (Rev.) is the Report of Suspected Child Abuse or Neglect.
Who signs: SIGN the Reporter's Signature line and enter the Position and the Date.
A filled-in Form DCF-136 example: a school nurse files the report
How to fill out Form DCF-136, box by box
The child, race and address
Please Print or Type the Child's Name.
Enter the Age Or DOB.
Under Race, the boxes are American Indian or Alaskan Native, Asian/Pacific Islander, Black/African American (not of Hispanic Origin), Hispanic, White (not of Hispanic origin), Unknown and Other. Enter the Child's Address.
Parents or other person responsible for the child's care
Enter the Name Of Parents Or Other Person Responsible For Child's Care, then the Address and the Phone Number.
The Careline worker and the dates
Enter the Name Of Careline Worker To Whom Oral Report Was Made and the Date Of Oral Report.
Enter the Date And Time Of Suspected Abuse/Neglect.
The suspected perpetrator
Enter the Name Of Suspected Perpetrator, If Known, the Address And Phone Number, If Known, and the Relationship To Child.
The injury and how it came to be known
Enter the Nature And Extent Of Injury(ies), Maltreatment Or Neglect.
Describe The Circumstances Under Which The Injury(ies), Maltreatment Or Neglect Came To Be Known.
Reasons, previous injury and prior cases
Describe the Reasons Such Persons(s) Are Suspected of Causing Such Injuries, Maltreatment of Neglect. Enter Information Concerning Any Previous Injury(ies), Maltreatment Or Neglect Of The Child Or His/Her Siblings and 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.
Siblings and the action taken
List Names And Ages Of Siblings, If Known, and What Action, If Any, Has Been Taken To Treat, Provide Shelter Or Otherwise Assist The Child.
REPORTER SECTION and Reporter's Race
In the REPORTER SECTION, enter the Reporter's Name, Agency Name, Phone Number, Agency Address and City.
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 and Other.
Reporter's Signature, position and date
SIGN the Reporter's Signature line and enter the Position and the Date.
More rules for Form DCF-136
WHITE COPY: TO DCF AREA OFFICE. If you need additional space, you may attach more documentation.
Any person, good faith and forty-eight hours
Any person having reasonable cause to suspect
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.
You report in good faith
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.
Within forty-eight hours of making an oral report
Within forty-eight hours of making an oral report, a mandated reporter shall submit this form (DCF-136) to the relevant Area Office.
Before you go
Careline 1-800-842-2288.
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.
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.
Common questions about Form DCF-136
Is there a penalty?
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. 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 (checked November 1, 2026).
Sources
[1] Form DCF-136 (05/2015 Rev.), Report of Suspected Child Abuse or Neglect, Connecticut Department of Children and Families (the Official source link on this page).
