Child Protection Referral Form

Child Protection Referral Form
Report Information
Disclaimer: Information submitted on this form will be sent via email. To protect sensitive information, do not request the following information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, and passwords.
Please complete the Child Protection Referral form to the best of your ability. Oral reporting: dial (507) 304-4444, Option 1.

For Mandated Reporters: Mandated Reporting Law, M.S. 626.556, requires reports to be phoned in immediately orally and forwarded in written form within 72 hours.
- Date of this report
  
  MonthDayYear
- Reporter*
  Your Name
- Agency
  If affiliated with an agency
- Reporter/Agency Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Reporter Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Reporter Relationship to Child(ren)
- Want to know Screening Outcome
- Please list all known children in the home, even if your observations only apply to an individual child. You will have an opportunity to provide details of what you observed later in the form. Supply as much information as you know. No details are required, but any details you can provide help us to make better decisions regarding the outcome of this report.
- Children in the home
- Children in the home*
- Supply as much information as you know. No details are required, but any details you can provide help us to make better decisions regarding the outcome of this report.
  
  If you need more space for any details, please add it to the "Other Details" section at the end of this form.
- Parent Information
- Parent(s)
- Supply as much information as you know. No details are required, but any details you can provide help us to make better decisions regarding the outcome of this report.
  
  If you need more space for any details, please add it to the "Other Details" section at the end of this form.
- Other Adult Information
- Other Adults in the home
- Maltreatment Information
- Supply as much information as you know. No details are required, but any details you can provide help us to make better decisions regarding the outcome of this report.
  
  If you need more space for any details, please add it to the "Other Details" section at the end of this form.
- Physical AbuseNeglectSexual AbuseMental Injury
- Personal ObservationLearned InformationOther
- Basis of Knowledge Detail
  If you answered "Learned Information" or "Other", please provide detail
- Location Where Maltreatment Occurred/Occurring
- Incident Date and Time
  
  MonthDayYear
  Hour MinutesAM/PM Option
- Physical Injury*
- If injury occurred, please describe the injury
- Nature of problem
  Please provide as much details and specific information as possible
- Previous and/or Current Services/Supports
- Family Strengths
  Describe what is going well for the family
- Other Details
  If there are other details of which we should be aware, please enter them here.
- Your form is now ready to be submitted. If you would like to receive a copy of your submission, please check the box below and provide an email address for the submission to be sent.
- Receive an email copy of this form
- Email Address
  example@example.com
- - Click “Submit” to send your form to Blue Earth County Human Services. If you provided an email address, you will also receive a confirmation email with a copy of your submitted form.
  - Click “Save for Later” to save your progress. You will receive an email with a link to return to your form and submit it at a later time.
    
    Note: Blue Earth County will not receive your form until you click “Submit.”
  - Click “Clear Form” to remove all entries and start over.
- Should be Empty:

Child Protection Referral Form

Report Information

Children in the home

Parent Information

Other Adult Information

Maltreatment Information