The DHS 3200 form is a document used to report actual or suspected child abuse or neglect to the Michigan Department of Human Services. This form serves as a written follow-up to an oral report and must be completed by the reporting person with specific details about the child, the alleged perpetrator, and the circumstances surrounding the suspected abuse or neglect. Timely and accurate completion of this form is crucial for ensuring the safety and well-being of the child involved.
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The Dhs 3200 form serves as a critical tool for reporting actual or suspected cases of child abuse or neglect in Michigan. Designed by the Michigan Department of Human Services, this form guides individuals through the process of documenting essential information regarding the child or children involved, as well as the circumstances surrounding the allegations. Key sections require details about the child’s identity, including their name, birth date, and social security number, along with information about the parents or guardians. The form also prompts the reporter to provide a description of the suspected abuse or neglect, the relationship of the alleged perpetrator to the child, and the address where the incident occurred. Medical professionals have specific sections to complete, which include summaries of physical examinations and any relevant medical documentation. It is vital for the reporting individual to fill out the form as thoroughly as possible and submit it to Centralized Intake, either by mail, fax, or email, ensuring that the matter is addressed promptly. In completing this form, reporters play a crucial role in safeguarding vulnerable children and facilitating the necessary interventions to protect their well-being.
REPORT OF ACTUAL OR SUSPECTED CHILD ABUSE OR NEGLECT
Michigan Department of Human Services
Was complaint phoned to DHS?
If no, contact Centralized Intake (855-444-3911) immediately
Yes
No
If yes, Log #
INSTRUCTIONS: REPORTING PERSON: Complete items 1-19 (20-28 should be completed by medical personnel, 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)
1. Date
NAME
BIRTH DATE
SOCIAL SECURITY #
SEX
RACE
3.
Mother’s name
4.
Father’s name
7. County
5.
Child(ren)’s address (No. & Street)
6. City
8. Phone No.
child(ren)
9.
Name of alleged perpetrator of abuse or neglect
10.
Relationship to
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
11
School Nurse
42
DHS Facility Social Worker
02
Hosp/Clinic Physician/Physician’s Assistant
12
Teacher
43
DMH Facility Social Worker
03
Coroner/Medical Examiner
13
School Administrator
44
Other Public Social Worker
04
Dentist/Register Dental Hygienist
14
School Counselor
45
Private Agency Social Worker
05
Audiologist
21
Law Enforcement
46
Court Social Worker
06
Nurse (Not School)
22
Domestic Violence Providers
47
Other Social Worker
07
Paramedic/EMT
23
Friend of the Court
48
FIS/ES Worker/Supervisor
08
Psychologist
25
Clergy
49
Social Services Specialist/Manager (CPS, FC, etc.)
09
Marriage/Family Therapist
31
Child Care Provider
56
Court Personnel
10
Licensed Counselor
41
Hospital/Clinic Social Worker
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
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
17a. Name of reporting
17b. Address (No. & Street)
17c. City
17d. State
17e. Zip Code
17f. Phone No.
18. Reporting person’s name
18a. Name of reporting
18b. Address (No. & Street)
18c. City
18d. State
18e. Zip Code
18f. Phone No.
19. Reporting person’s name
19a. Name of reporting
19b. Address (No. & Street)
19c. City
19d. State
19e. Zip Code
19f. Phone No.
DHS-3200 (Rev. 10-12) 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
22. X-Ray
23.
Other (specify)
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
AUTHORITY:
P.A. 238 of 1975.
because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual
COMPLETION:
Mandatory.
orientation, gender identity or expression, political beliefs or disability. If you need help with
PENALTY:
None.
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.
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 616-977-8900 or 616-977-8050 or 616-977-1158 or 616-977-1154
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.
2
Filling out the Dhs 3200 form is a crucial step in reporting suspected child abuse or neglect. Once completed, this form needs to be sent to the Centralized Intake for Abuse & Neglect. This ensures that the report is officially documented and can be acted upon by the appropriate authorities.
After completing the form, send it to the Centralized Intake for Abuse & Neglect at the specified address or fax it to the provided numbers. Email submission is also an option. Ensure all sections are filled out accurately to facilitate a prompt response.
What is the purpose of the Dhs 3200 form?
The Dhs 3200 form is used to report actual or suspected child abuse or neglect in Michigan. It serves as a written follow-up to an oral report made to the Department of Human Services (DHS). The form collects essential information about the child or children involved, the suspected perpetrator, and the circumstances surrounding the abuse or neglect. Completing this form is a crucial step in ensuring the safety and well-being of the child.
Who is required to fill out the Dhs 3200 form?
The form is primarily to be completed by the reporting person, who may be a professional such as a teacher, doctor, or social worker. They must fill out items 1-19. If a physical examination has been conducted, medical personnel are responsible for completing items 20-28. It is vital that the form is filled out as completely and accurately as possible to facilitate a thorough investigation.
How do I submit the Dhs 3200 form?
You can submit the Dhs 3200 form by mailing it to Centralized Intake for Abuse & Neglect at the address provided on the form. Alternatively, you may fax it to the designated numbers or email it to the specified email address. Ensure that you choose the submission method that is most convenient for you, but do not delay in sending the report, as timely action is essential.
What information is needed about the child or children?
You will need to provide the names, birth dates, social security numbers, sex, and race of the child or children suspected of being abused or neglected. Additionally, you should include their address and contact information. If applicable, mention any disabilities that may require accommodations. This information is critical for the authorities to identify and protect the child or children involved.
What should I include in the description of the suspected abuse or neglect?
In this section, describe any injuries, conditions, or circumstances that led to your suspicion of abuse or neglect. Be as detailed as possible, including the nature of the injuries and the context in which they occurred. This information will help investigators understand the severity and nature of the situation, allowing them to take appropriate action.
What happens after I submit the Dhs 3200 form?
Once the Dhs 3200 form is submitted, it will be reviewed by the Centralized Intake team at DHS. They will assess the information provided and determine whether further investigation is warranted. If necessary, they will initiate contact with law enforcement or other relevant agencies to ensure the safety of the child or children involved. Your report is a critical first step in this process.
Is there a penalty for not reporting suspected child abuse or neglect?
While there is no specific penalty outlined for failing to report suspected abuse or neglect, it is important to understand that not reporting can have serious consequences for the child involved. Professionals in certain fields, such as healthcare and education, are mandated reporters and are legally required to report suspicions of abuse or neglect. Failing to do so may lead to disciplinary actions within their profession.
Completing the Dhs 3200 form requires careful attention to detail. One common mistake is failing to provide the date when the form is completed. This date is crucial for tracking the timeline of the report. Without it, the report may lack context, which can affect the investigation.
Another frequent error involves omitting essential information about the child(ren) suspected of abuse or neglect. It is important to include all available details, such as names, birth dates, and social security numbers. Incomplete information can hinder the ability of authorities to respond effectively.
Many individuals also neglect to specify the relationship of the alleged perpetrator to the child. This information is vital for understanding the dynamics of the situation. By failing to provide this detail, the report may lack clarity, making it more challenging for investigators to assess the risk involved.
Additionally, some reporting individuals forget to include the address where the abuse or neglect occurred. This omission can delay the investigation, as authorities may need to gather this information later. Providing a complete address ensures that the response is timely and appropriate.
Another mistake is not describing the injuries or conditions observed. The report should include a clear description of the circumstances that led to the suspicion of abuse or neglect. Without this critical information, the investigation may lack the necessary context to proceed effectively.
Failing to indicate the source of the complaint is another common oversight. It is essential to check the appropriate box for the professional group or category from which the report originates. This helps authorities understand the perspective of the reporter and the basis for the suspicion.
Some individuals do not provide their contact information accurately. This can create complications if investigators need to follow up for additional information. It is important to ensure that all contact details are correct and up-to-date.
Furthermore, the form requires multiple reporting persons to fill out their information. A mistake often made is not completing all required sections for each reporting individual. Each person involved in the report should provide their name, organization, and contact details to ensure comprehensive communication.
Finally, individuals sometimes fail to send the form to the correct address or use the appropriate submission method. It is important to follow the instructions carefully to ensure that the report reaches the Centralized Intake for Abuse & Neglect without delay.
The DHS 3200 form serves as a critical tool for reporting suspected child abuse or neglect in Michigan. Along with this form, several other documents and forms may be required to ensure a comprehensive approach to child welfare. Below is a list of these documents, each accompanied by a brief description.
These documents work together to create a comprehensive framework for addressing child abuse and neglect. Proper documentation and timely reporting are essential to protect vulnerable children and ensure their safety and well-being.
The DHS 3200 form is essential for reporting suspected child abuse or neglect. Several other documents serve similar purposes in different contexts. Here’s a list of those documents and how they relate to the DHS 3200 form:
When filling out the Dhs 3200 form, it’s essential to approach the process with care. Here are five things you should and shouldn't do:
By keeping these points in mind, you can help ensure that your report is processed efficiently and effectively. The safety of children is the priority, and accurate reporting plays a critical role in that effort.
Misconceptions about the DHS 3200 Form
Here are some key takeaways about filling out and using the Dhs 3200 form: