Dcfs Cw Form Cpi 2 – Fill Out and Use This PDF

Confidential

Department of Children and Family Services/Child Welfare

Written Report Form for Mandated Reporters of Child Abuse/Neglect

I understand that I am making a report of child abuse and/or neglect in good faith and in accordance with the Louisiana Children’s Code, Article 610 D. which requires me, as a mandated reporter, to send a written report to the Department of Children and Family Services (DCFS) or law enforcement within five days of having made an initial oral report. I understand that I may report suspected abuse and/or neglect in writing instead of an oral report.

Use: This form is available for you to use to make a written report of child abuse and/or neglect to DCFS or law enforcement. If you are unable to print out the form, contact any DCFS parish or regional office and one will be sent to you.

Completion: Complete each item with information known by you that may be pertinent to the suspected abuse/neglect. If there are items for which you have no information, please complete with “Unknown”. It is not necessary for you to try and get all information requested. If you need more space, please add a page. Once completed, it may be printed out and mailed or faxed to the DCFS office for the parish where the child lives or where you made the report. The local offices, addresses and fax numbers are on this web site (www.dcfs.la.gov.). If you have not yet made a report to DCFS, please fax this form as soon as possible. Thank you for your interest and commitment to the safety and well being of children.

This Written Report is:	Initial Written Report to DCFS		Report to Law Enforcement
Follow-up to oral report to DCFS on: (Date)			to (Parish)
DCFS Office

Suspected Child Victim(s):
1.	Name:		DOB/Age:		Race:		Sex:
2.	Name:		DOB/Age:		Race:		Sex:
3.	Name:		DOB/Age:		Race:		Sex:

Home Address:

Telephone:

Parents/Caretakers Names:

Others in Home:

Age:

Race:

Sex:

(Children & Adults

if known)

Age:

Race:

Sex:

Age:

Race:

Sex:

Age:

Race:

Sex:

Suspected Perpetrator(s):

Relationship to Child:

Suspected Perpetrator(s):

Relationship to Child:

Suspected Perpetrator’s Address:

Nature, extent and cause of each child’s injuries, neglect or endangered condition, including any previous known or suspected abuse to this child or the child’s siblings:

Page 1	DCFS/CW Form CPI-2
	Reissued: 01/12	Replacing: 6/08

Suspected Child Victim’s Name (from Page 1):

What is current circumstance/condition of the child victim and are they currently in danger of serious injury or harm? Why?

Identity of any child or adult who gave any explanation of the child’s injury or condition, along with the date and details of the explanation:

How and when did this child(ren) victim come to your attention?

What services and/or referrals have been provided to the child/family by you or your agency/facility?

Have you previously reported abuse/neglect on this child or any of his siblings?

No

Yes

If yes, please give number of times, approximate dates, persons reported, office to which reported and outcome, if known:

What is going well for the family; areas of parenting they handle adequately; and, was there a time when they adequately cared for or protected the child(ren), if known?

Other Pertinent Information (other persons with information about the family and way to contact)

Reporter’s Printed Name:

Phone # to Contact:

Signature:

Date:

Best Contact Time:

Position/Type of Reporter:

Agency/Provider:

Reporter’s Address:

Page 2	DCF/CW Form CPI-2
	Reissued: 01/12	Replacing: 6/08