DCFS/CW Form CPI-2 at a glance
What it is: This is the Confidential Department of Children and Family Services/Child Welfare Written Report Form for Mandated Reporters of Child Abuse/Neglect.
Who signs: Sign at Signature, then enter the Date, Best Contact Time, Position/Type of Reporter and Agency/Provider.
A mandated reporter may report suspected abuse and/or neglect in writing instead of an oral report.
A filled-in DCFS/CW Form CPI-2 example: a nurse reports one child
How to fill out DCFS/CW Form CPI-2, box by box
This Written Report is
This Written Report is an Initial Written Report to DCFS, a Report to Law Enforcement, or a Follow-up to oral report to DCFS on a (Date) to a (Parish) DCFS Office.
Is there any danger to a worker?
Is there any danger to a worker? Mark None known or Yes, Explain.
Suspected Child Victim(s)
For Suspected Child Victim(s) 1, fill in the Name, DOB/Age, Race and Sex.
For Suspected Child Victim(s) 2, fill in the Name, DOB/Age, Race and Sex.
For Suspected Child Victim(s) 3, fill in the Name, DOB/Age, Race and Sex. Then fill in the Home Address, Telephone and Parents/Caretakers Names.
Others in Home
Under Others in Home (Children & Adults if known), fill in each of the Others in Home, with the Age, Race and Sex.
Suspected Perpetrator(s)
Fill in each Suspected Perpetrator(s) and the Relationship to Child, then the Suspected Perpetrator's Address.
Nature, extent and cause
Enter the 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.
Suspected Child Victim's Name (from Page 1) and the child's circumstance
Enter the Suspected Child Victim's Name (from Page 1).
Enter the current circumstance/condition of the child victim: are they currently in danger of serious injury or harm? Why?
Give the 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.
Enter how and when this child(ren) victim come to your attention.
Enter what services and/or referrals have been provided to the child/family by you or your agency/facility.
Have you previously reported abuse/neglect
Mark No or Yes: have you previously reported abuse/neglect on this child or any of his siblings?
If yes, give the number of times, approximate dates, persons reported, office to which reported and outcome, if known.
What is going well for the family
Enter 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
Under Other Pertinent Information, list other persons with information about the family and the way to contact them.
Reporter's Printed Name, signature and contact
Enter the Reporter's Printed Name and the Phone # to Contact.
Sign at Signature, then enter the Date, Best Contact Time, Position/Type of Reporter and Agency/Provider.
Enter the Reporter's Address.
More rules for DCFS/CW Form CPI-2
Use this form to make a written report of child abuse and/or neglect to DCFS or law enforcement.
The reporter understands that the report of child abuse and/or neglect is made in good faith and in accordance with the Louisiana Children's Code, Article 610 D.
The local offices, addresses and fax numbers are on the web site www.dcfs.la.gov.
If you have not yet made a report to DCFS, please fax this form as soon as possible.
If you are unable to print out the form, contact any DCFS parish or regional office and one will be sent to you.
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.
Common questions about DCFS/CW Form CPI-2
Is there a deadline?
A mandated reporter must 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.
Where do I file it?
Once completed, the form 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.
Sources
[1] DCFS/CW Form CPI-2 (Reissued 01/12), Written Report Form for Mandated Reporters of Child Abuse/Neglect, Louisiana Department of Children and Family Services (the Official source link on this page).