Child Maltreatment Referral Form Instructions
This file provides instructions for completing the Child Maltreatment Referral Form, which is used by Arizona Child Fatality Review Teams to report child abuse or neglect. It defines mandatory reporting requirements, specifies when and how to complete the form, and details the routing procedure.
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How do I fill this out?
To fill out the Child Maltreatment Referral Form, you need to provide detailed information about the child, parents, and incident of maltreatment. Carefully follow the instructions provided to ensure all necessary details are included. Once completed, submit the form as directed.
How to fill out the Child Maltreatment Referral Form Instructions?
1
Provide the date of referral and child's details including name, date of birth, and date of death.
2
Fill in the details of the child's parents, including names and dates of birth.
3
Indicate the nature of maltreatment and provide details of the perpetrator.
4
Describe the maltreatment incident with as much detail as possible.
5
Submit the completed form to the CPS Child Abuse Hotline immediately.
Who needs the Child Maltreatment Referral Form Instructions?
1
Child Fatality Review Team members need this form for mandatory reporting of child abuse or neglect.
2
Social workers may need this form to document cases of suspected child maltreatment.
3
Healthcare professionals might use this form to report cases of abuse or neglect they observe.
4
Legal professionals involved in child welfare cases may need the form for documentation purposes.
5
Law enforcement officers could require this form when investigating child maltreatment incidents.
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What are the instructions for submitting this form?
To submit this form, call the CPS Child Abuse Hotline at 1-888-SOS-CHILD and provide the necessary information. Ensure the form is completed to the best of your ability and attach the completed case review data reporting form. After calling the hotline, mail the completed form and the completed case review data reporting form to Arizona Department of Health Services. For further guidance, contact your local team coordinator or refer to the detailed instructions provided in the form.
What is the purpose of this form?
The primary purpose of this form is to facilitate mandatory reporting of child maltreatment by members of Arizona Child Fatality Review Teams. It aims to gather essential information about the deceased child, their family, and the nature of the maltreatment incident. This information is crucial for Child Protective Services to investigate and ensure the safety of other children in the household.
Tell me about this form and its components and fields line-by-line.
- 1. Date of Referral: The date on which the referral is made.
- 2. Child's Name: Full name of the child, including any other names used previously.
- 3. Date of Birth: Child's date of birth.
- 4. Date of Death: The child's date of death, if applicable.
- 5. Mother's Name: Full name of the mother, including any other names used previously.
- 6. Mother's Date of Birth: Mother's date of birth.
- 7. Father's Name: Full name of the father, including any other names used previously.
- 8. Father's Date of Birth: Father's date of birth.
- 9. Nature of Maltreatment: Type of maltreatment, such as physical abuse, sexual abuse, or neglect.
- 10. Name of Perpetrator: Full name of the perpetrator.
- 11. Relationship of Perpetrator to Child: The perpetrator's relationship to the child.
- 12. Description of Maltreatment Incident: Detailed description of the maltreatment incident and any relevant information.
- 13. Name of Person Making Report: Full name of the individual making the report.
- 14. Telephone: Contact telephone number of the person making the report.
- 15. Email Address of Local Team Coordinator: Email address for the local team coordinator.
What happens if I fail to submit this form?
Failing to submit this form can have serious consequences, including the possibility of continued harm to other children in the household. It may also result in legal ramifications for mandated reporters.
- Endangerment of Other Children: Without reporting, other children may remain at risk of harm or maltreatment.
- Legal Consequences for Reporters: Mandated reporters may face legal penalties for failing to report suspected child maltreatment.
How do I know when to use this form?
- 1. Suspected Physical Abuse: When there are signs or evidence of physical abuse leading to a child's death.
- 2. Suspected Sexual Abuse: When sexual abuse is suspected to have contributed to a child's death.
- 3. Neglect: In cases where neglect is believed to have led to the death of a child.
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