Dhs 3200 PDF Details

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QuestionAnswer
Form NameDhs 3200
Form Length2 pages
Fillable?Yes
Fillable fields95
Avg. time to fill out19 min 34 sec
Other names3200 form state of michigan, cps form 3200 michigan, dhs michigan form 3200, michigan dhs 3200

Form Preview Example

REPORT OF ACTUAL OR SUSPECTED CHILD ABUSE OR NEGLECT

Michigan Department of Human Services

Was complaint phoned to DHS?

 

 

 

If no, contact

 

 

 

 

 

 

 

 

 

Yes

No

If yes, Log #

 

 

 

Centralized Intake (855-444-3911) immediately

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS: REPORTING PERSON: Complete items 1-19 (20-28 should be completed by medical personnel,

1. Date

 

 

if applicable). Send to Centralized Intake at the address list on page 2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

List of child(ren) suspected of being abused or neglected (Attach additional sheets if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

BIRTH DATE

 

SOCIAL SECURITY #

 

SEX

 

RACE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Mother’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Father’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Child(ren)’s address (No. & Street)

 

 

 

6. City

 

7. County

 

8. Phone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Name of alleged perpetrator of abuse or neglect

 

 

 

10. Relationship to child(ren)

 

 

 

 

 

 

 

 

 

 

 

11. Person(s) the child(ren) living with when abuse/neglect occurred

 

12. Address, City & Zip Code where abuse/neglect occurred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Describe injury or conditions and reason for suspicion of abuse or neglect

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Source of Complaint (Add reporter code below)

 

 

 

 

 

 

 

 

 

 

 

 

 

01

Private Physician/Physician’s Assistant

13

School Administrator

 

45

Private Agency Social Worker

 

 

02

Hosp/Clinic Physician/Physician’s Assistant

14

School Counselor

 

46

Court Social Worker

 

 

03

Coroner/Medical Examiner

 

21

Law Enforcement

 

47

Other Social Worker

 

 

04

Dentist/Register Dental Hygienist

22

Domestic Violence Providers

48

FIS/ES Worker/Supervisor

 

 

05

Audiologist

 

 

23

Friend of the Court

 

49

Social Services Specialist/Manager (CPS, FC, etc.)

06

Nurse (Not School)

 

25

Clergy

 

51

Hospital/Clinic Personnel

 

 

07

Paramedic/EMT

 

31

Child Care Provider

 

52

DHS Facility Personnel

 

 

08

Psychologist

 

 

41

Hospital/Clinic Social Worker

53

DMH Facility Personnel

 

 

09

Marriage/Family Therapist

 

42

DHS Facility Social Worker

54

Other Public Social Agency Personnel

 

 

10

Licensed Counselor

 

43

DMH Facility Social Worker

55

Private Social Agency Personnel

 

 

11

School Nurse

 

 

44

Other Public Social Worker

56

Court Personnel

 

 

 

 

 

 

12 Teacher

15. Reporting person’s name

Report Code (see above)

15a. Name of reporting organization (school, hospital, etc.)

 

 

 

 

 

 

15b. Address (No. & Street)

 

15c. City

15d. State

15e. Zip Code

15f. Phone No.

 

 

 

 

 

 

16. Reporting person’s name

Report Code (see above)

16a. Name of reporting organization (school, hospital, etc.)

 

 

 

 

 

 

16b. Address (No. & Street)

 

16c. City

16d. State

16e. Zip Code

16f. Phone No.

 

 

 

 

 

 

17. Reporting person’s name

Report Code (see above)

17a. Name of reporting organization (school, hospital, etc.)

 

 

 

 

 

 

17b. Address (No. & Street)

 

17c. City

17d. State

17e. Zip Code

17f. Phone No.

 

 

 

 

 

 

18. Reporting person’s name

Report Code (see above)

18a. Name of reporting organization (school, hospital, etc.)

 

 

 

 

 

 

18b. Address (No. & Street)

 

18c. City

18d. State

18e. Zip Code

18f. Phone No.

 

 

 

 

 

 

19. Reporting person’s name

Report Code (see above)

19a. Name of reporting organization (school, hospital, etc.)

 

 

 

 

 

 

19b. Address (No. & Street)

 

19c. City

19d. State

19e. Zip Code

19f. Phone No.

 

 

 

 

 

 

DHS-3200 (Rev. 2-12) Previous edition may be used. MS Word

1

TO BE COMPLETED BY MEDICAL PERSONNEL WHEN PHYSICAL EXAMINATION HAS BEEN DONE

20. Summary report and conclusions of physical examination (Attach Medical Documentation)

21.Laboratory report

23.Other (specify)

22. X-Ray

24. History or physical signs of previous abuse/neglect

YES

NO

25. Prior hospitalization or medical examination for this child

DATES

PLACES

26. Physician’s Signature

27. Date

28. Hospital (if applicable)

Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.

AUTHORITY:

P.A. 238 of 1975.

COMPLETION:

Mandatory.

PENALTY:

None.

INSTRUCTIONS

GENERAL INFORMATION:

This form is to be completed as the written follow-up to the oral report (as required in Sec. 3 (1) of 1975 PA 238, as amended) and mailed to Centralized Intake for Abuse & Neglect. Indicate if this report was phoned into DHS as a report of suspected CA/N. If so, indicate the Log

# (if known). The reporting person is to fill out as completely as possible items 1-19. Only medical personnel should complete items 20-28.

Mail this form to:

Centralized Intake for Abuse & Neglect 5321 28th Street Court S.E.

Grand Rapids, MI 49546

OR

Fax this form to 616-977-1154 or 616-977-1158

Or email this form to DHS-CPS-CIGroup@michigan.gov

1.Date – Enter the date the form is being completed.

2.List child(ren) suspected of being abused or neglected – Enter available information for the child(ren) believed to be abused or neglected. Indicate if child has a disability that may need accommodation.

3.Mother’s name – Enter mother’s name (or mother substitute) and other available information. Indicate if mother has a disability that may need accommodation.

4.Father’s name – Enter father’s name (or father substitute) and other available information. Indicate if father has a disability that may need accommodation.

5.-7. Child(ren)’s address – Enter the address of the child(ren).

8.Phone – Enter phone number of the household where child(ren) resides.

9.Name of alleged perpetrator of abuse or neglect – Indicate person(s) suspected or presumed to be responsible for the alleged abuse or neglect.

10.Relationship to child(ren) – Indicate the relationship to the child(ren) of the alleged perpetrator of neglect or abuse, e.g., parent, grandparent, babysitter.

11.Person(s) child(ren) living with when abuse/neglect occurred – Enter name(s). Indicate if individuals have a disability that may need accommodation.

12.Address where abuse / neglect occurred.

13.Describe injury or conditions and reason of suspicion of abuse or neglect – Indicate the basis for making a report and the information available about the abuse or neglect.

14.Source of complaint – Check appropriate box noting professional group or appropriate category.

Note: If abuse or neglect is suspected in a hospital, also check hospital.

DHS Facility – Refers to any group home, shelter home, halfway house or institution operated by the Department of Human Services.

DCH Facility – Refers to any institution or facility operated by the Department of Community Health.

15.-19 - Reporting person’s name - Enter the name and address of person(s) reporting this matter.

DHS-3200 (Rev. 2-12) Previous edition may be used. MS Word

2

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step 1 to completing dhs3200

You need to type in the information within the segment 01 Private Physician/Physician’s, 13 School Administrator 14 School, 45 Private Agency Social Worker 46, 15b, Report Code (see above) 15a, 15c, 15d, and 15f.

dhs3200 01 Private Physician/Physician’s, 13 School Administrator 14 School, 45 Private Agency Social Worker 46, 15b, Report Code (see above) 15a, 15c, 15d, and 15f fields to fill

Jot down the vital particulars in 16b, 17b, 18b, 19b, Report Code (see above) 16a, 16c, 16d, 16f, Report Code (see above) 17a, 17c, 17d, 17f, Report Code (see above) 18a, 18c, 18d, 18f, Report Code (see above) 19a, 19c, 19d, 19f, and DHS-3200 (Rev section.

Entering details in dhs3200 part 3

Be sure to describe the rights and obligations of the parties in the YES, DATES, PLACES, Department of Human Services (DHS), AUTHORITY: COMPLETION: Mandatory, and None field.

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