Use the tab key to navigate through the form.  
Do not use the enter key as your form may be erroneously submitted as an incomplete report.

* Required Fields.

Reporter - Your Name

First: * Middle: Last: *

Phone #: * Ext: Phone Type:* Select One Business Business Cell Residence Residence Cell Gender : Male Female

Street: * Address Type: * Select One Business Residence

City: * State:* TX AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN UT VA VT WA WI WV WY Zip:

County: * Select One Anderson Andrews Angelina Aransas Archer Armstrong Atascosa Austin Bailey Bandera Bastrop Baylor Bee Bell Bexar Blanco Borden Bosque Bowie Brazoria Brazos Brewster Briscoe Brooks Brown Burleson Burnet Caldwell Calhoun Callahan Cameron Camp Carson Cass Castro Chambers Cherokee Childress Clay Cochran Coke Coleman Collin Collingsworth Colorado Comal Comanche Concho Cooke Coryell Cottle Crane Crockett Crosby Culberson Dallam Dallas Dawson Deaf smith Delta Denton Dewitt Dickens Dimmit Donley Duval Eastland Ector Edwards Ellis El paso Erath Falls Fannin Fayette Fisher Floyd Foard Fort bend Franklin Freestone Frio Gaines Galveston Garza Gillespie Glasscock Goliad Gonzales Gray Grayson Gregg Grimes Guadalupe Hale Hall Hamilton Hansford Hardeman Hardin Harris Harrison Hartley Haskell Hays Hemphill Henderson Hidalgo Hill Hockley Hood Hopkins Houston Howard Hudspeth Hunt Hutchinson Irion Jack Jackson Jasper Jeff davis Jefferson Jim hogg Jim wells Johnson Jones Karnes Kaufman Kendall Kenedy Kent Kerr Kimble King Kinney Kleberg Knox Lamar Lamb Lampasas La salle Lavaca Lee Leon Liberty Limestone Lipscomb Live oak Llano Loving Lubbock Lynn Madison Marion Martin Mason Matagorda Maverick Mcculloch Mclennan Mcmullen Medina Menard Midland Milam Mills Mitchell Montague Montgomery Moore Morris Motley Nacogdoches Navarro Newton Nolan Nueces Ochiltree Oldham Orange Palo pinto Panola Parker Parmer Pecos Polk Potter Presidio Rains Randall Reagan Real Red river Reeves Refugio Roberts Robertson Rockwall Runnels Rusk Sabine San augustine San jacinto San patricio San saba Schleicher Scurry Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Swisher Tarrant Taylor Terrell Terry Throckmorton Titus Tom green Travis Trinity Tyler Upshur Upton Uvalde Val verde Van zandt Victoria Walker Waller Ward Washington Webb Wharton Wheeler Wichita Wilbarger Willacy Williamson Wilson Winkler Wise Wood Yoakum Young Zapata Zavala Out of state -None-

Place of Employment: Your relationship to the victim/client: Select One Community Agency Attorney Aunt\Uncle Passer-by Cousin Clergy Court Daughter Day Care Fac./Prov. Doctor EMS\EMT Financial Institute Other Family member Friend Family Viol. Shelter Grandchild Grandparent Guardian Atty/Gua Ad Litem In-Law Option Institution Law Enforcement Medical Fac. Staff Mental Health Prof. Neighbor Niece\Nephew Nurse Other Shelter Parent Clnt's Paramour(APS) Par's Paramour Service Provider Psychlgst/Psychitrst Other St. Agency Sibling School Personnel FPS staff Son Spouse Therapist Unrel. Home mem. Victim Other Parole/Probation Officer

When can you be reached (days and time)?*

Victim Child - The child you are primarily concerned about.

First: * Middle: Last: *

Home Address: *
If Rural Rt. or P.O. Box, provide directions to the home.
Unknown

City: * State:* TX AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN UT VA VT WA WI WV WY Zip:

County: * Select One Anderson Andrews Angelina Aransas Archer Armstrong Atascosa Austin Bailey Bandera Bastrop Baylor Bee Bell Bexar Blanco Borden Bosque Bowie Brazoria Brazos Brewster Briscoe Brooks Brown Burleson Burnet Caldwell Calhoun Callahan Cameron Camp Carson Cass Castro Chambers Cherokee Childress Clay Cochran Coke Coleman Collin Collingsworth Colorado Comal Comanche Concho Cooke Coryell Cottle Crane Crockett Crosby Culberson Dallam Dallas Dawson Deaf smith Delta Denton Dewitt Dickens Dimmit Donley Duval Eastland Ector Edwards Ellis El paso Erath Falls Fannin Fayette Fisher Floyd Foard Fort bend Franklin Freestone Frio Gaines Galveston Garza Gillespie Glasscock Goliad Gonzales Gray Grayson Gregg Grimes Guadalupe Hale Hall Hamilton Hansford Hardeman Hardin Harris Harrison Hartley Haskell Hays Hemphill Henderson Hidalgo Hill Hockley Hood Hopkins Houston Howard Hudspeth Hunt Hutchinson Irion Jack Jackson Jasper Jeff davis Jefferson Jim hogg Jim wells Johnson Jones Karnes Kaufman Kendall Kenedy Kent Kerr Kimble King Kinney Kleberg Knox Lamar Lamb Lampasas La salle Lavaca Lee Leon Liberty Limestone Lipscomb Live oak Llano Loving Lubbock Lynn Madison Marion Martin Mason Matagorda Maverick Mcculloch Mclennan Mcmullen Medina Menard Midland Milam Mills Mitchell Montague Montgomery Moore Morris Motley Nacogdoches Navarro Newton Nolan Nueces Ochiltree Oldham Orange Palo pinto Panola Parker Parmer Pecos Polk Potter Presidio Rains Randall Reagan Real Red river Reeves Refugio Roberts Robertson Rockwall Runnels Rusk Sabine San augustine San jacinto San patricio San saba Schleicher Scurry Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Swisher Tarrant Taylor Terrell Terry Throckmorton Titus Tom green Travis Trinity Tyler Upshur Upton Uvalde Val verde Van zandt Victoria Walker Waller Ward Washington Webb Wharton Wheeler Wichita Wilbarger Willacy Williamson Wilson Winkler Wise Wood Yoakum Young Zapata Zavala Out of state -None-

Home Phone #:

How long has the family lived at this address? (If known)

Age: * DOB: Gender: * Male Female       SSN:

School/Daycare/Facility: School/Daycare/Facility Address:

School/Daycare/Facility City: School/Daycare/Facility State: TX AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN UT VA VT WA WI WV WY

School/Daycare/Facility Zip Code: School/Daycare/Facility Phone: Ext:

Grade (if applicable):

Primary Language: Select One English French German Polish Sign Spanish Vietnamese Other Race/Ethnicity: Select One Am Indian/AK Native Asian Black Hispanic Native Hawaiian/Pacif Isl Unable to Determine White

Other children in the home (if any known):

Information about additional children may be listed in the section of this report where we ask you for any other information we need to know about the family.

Did one or more of the children listed above abuse/neglect the alleged victim(s)?
Yes No Unknown
Which child(ren) is the alleged abuser/neglector?

Adults who live in the home with victim child(ren):

Information about additional adults in the home may be listed in the section of this report where we ask you for any other information we need to know about the family.

If the person who allegedly abused or neglected the child(ren) does not live in the victim's home, please provide the following:

How often does this person have contact with the victim child(ren) and in what capacity?
Unknown

Are there children residing in this persons home? Yes No Unknown
If yes, provide names and ages, if known.

Others With Knowledge of Alleged Abuse/Neglect

Who else knows about the alleged abuse/neglect? Unknown

Please answer the following questions as fully as you are able:
(If you do not know the answer, please indicate this. You do not need to repeat any information that you have provided in a different section.)

Why do you suspect abuse/neglect?

What happened?* (What did the parent/relative/caretaker do to the child or fail to do for the child)
Provide details of the incident(s).

Was the child injured? Describe any injuries* [with description (location, size/dimension, color) of bruises, marks, welts,etc.].

Was (is) there a need for medical treatment/care?* If yes, explain medical treatment received or needed. (Provide names of doctor, therapist, medical facility, etc. if known).

How did you find out about this situation? Who told you about it? When did they tell you?*

Has the child told anyone about what happened?* Who? When? What did the child say? (Use the child’s wording, when possible)

Has the parent/caretaker been asked about the alleged abuse/neglect?* What was the parent/caretaker’s explanation? Who talked to the parent/caretaker? When?  

Describe the child’s emotional state/behaviors* (sad, out of control, crying excessively, withdrawn, suicidal, self-harming, etc.). When was this observed? By whom?

How have the parents/caretakers responded to the child's emotional state?*

Does the child have any special needs (MR, ED, physical disability, etc.)?* If so, what are they and how do they impact the child's level of functioning?

Is there history of abuse/neglect?

Are you aware of any other prior abuse/neglect to the child(ren)?* If yes, how often and when?

Do you know if it was reported to us?* Give previous call i.d. #s, if known

What are the family dynamics and home environment?

Are there any indications of alcohol/drug abuse, domestic violence, or parent/child conflict. Explain.*

Describe the family's support system i.e, relatives, community, church, etc.*

Describe how the parent/caretaker treats/interacts with the child? Is this child treated differently/scapegoated?* Explain.

Is the home a health and/or safety hazard for the child i.e. raw sewage, rodents, drugs/guns accessible to children, broken glass?* Describe the concerns.

Other Information

Is there any other information that we need to know about the family or this situation?
Give specifics.

Law Enforcement requirements:

We are required to notify the appropriate law enforcement jurisdiction of all reports alleging abuse/neglect to children.

Did the alleged abuse/neglect occur at the family’s home address? Yes No Unknown

If yes, to the best of your knowledge is the family address inside the city limits or outside the city limits unknown . Please mark one.

If the alleged abuse/neglect did not occur at the family’s home address, do you know where it occurred?