2. IF THIS IS AN EMERGENCY DIAL 911
   Please complete the online form below to report suspected abuse/neglect. All fields are mandatory even if the reply is "unknown" or "not applicable (n/a)". The use of profanity will cause the report submission to fail. Please be sure to provide your contact information if you feel the profanity is an essential part of your report and include a statement to that effect in the description of the nature and extent of the incident you are reporting.
4. Reporter's Information
6. Reporter's Name (first & last) or Anonymous *
8. Reporter's Phone Number: (include area code & alternate phone)*
9. Relationship to Child: (teacher, friend, neighbor, custodial or non-custodial parent)*
11. Address (Including city, state & zip)*
13. Child #1 Name, DOB or approximate age, and School Attending*
14. If Native American, list tribal affiliation*
16. Child #2 Name, DOB or approximate age, and School Attending*
17. If Native American, list tribal affiliation*
19. Address or location the neglect/abuse took place. *
21. Father's Name*
22. Father's Phone Number*
23. Mother's Name*
24. Mother's Phone Number*
26. Father's Address*
27. Mother's Address*
29. Describe the nature and extent of abuse/neglect and the circumstances leading to the suspicion that the child is a victim of neglect/abuse. Be as detailed as possible with date(s) of incident(s), injuries, alleged offender's name, location, other witnesses, etc..*
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field