Human Services 105 South 5 th Street, Suite 203h Olivia, MN

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1 Human Services 105 South 5 th Street, Suite 203h Olivia, MN REPORT OF ABUSE OR NEGLECT OF CHILDREN This report is prepared in connection with the mandatory reporting laws of the State of Minnesota, MN Statutes Section This report is made with the understanding that immunity from liability, civil or criminal, is given for any report made in good faith. This statute also states that a person required to report who negligently or intentionally 8fails to report is liable for damages caused by the failure. This report is also made with the understanding that Renville County Human Services shall investigate the circumstances and offer protective services to the abused or neglected child. It is understood that this written report will also be shared with Law Enforcement and the appropriate licensing agency or agencies. Voluntary reporters have access, upon request, to a concise summary of our assessment; mandated reporters have access to a summary of the assessment. When making a report, please be specific in identifying the child, the caretaker, the nature and extent of the suspected abuse or neglect, any evidence of previous abuse or neglect, and any information that might be helpful in the investigation of the suspected abuse or neglect. Following are pertinent definitions: 1. "Neglect" means failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, or medical care when reasonably able to do so, failure to protect a child from conditions or actions which imminently and seriously endanger the child's physical or mental health when reasonably able to do so, or failure to take steps to ensure that a child is educated in accordance with state law. Nothing in this section shall be construed to mean that a child is neglected solely because the child's parent, guardian, or other person responsible for the child's care in good faith selects and depends upon spiritual means or prayer for treatment or care of disease or remedial care of the child in lieu of medical care; except that there is a duty to report if a lack of medical care may cause imminent and serious danger to the child's health. This section does not impose upon persons, not otherwise legally responsible for providing a child with necessary food, clothing, shelter, education, or medical care, a duty to provide that care. "Neglect" includes prenatal exposure to a controlled substance, as defined in section 253B.02, subdivision 2 5, used by the mother for a nonmedical purpose, as evidenced by withdrawal symptoms in the child at birth, results of a toxicology test performed on the mother at delivery or the child at birth, or medical effects or developmental delays during the child's first year of life that medically indicate prenatal exposure to a controlled substance. Neglect also means "medical neglect" as defined in section subd 6, clause (5). 2. "Physical abuse" means any physical or mental injury or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means, or any physical or mental injury that cannot reasonably be explained by the child's history of injuries, or any aversive and deprivation procedures that have not been authorized under section "Sexual abuse" means the subjection of a child by a person responsible for the child's care, or by a person in a position of authority, as defined in section , subdivision 10 1, to any act which constitutes a violation of section , , , or Sexual abuse also includes any act which involves a minor which constitutes a violation of sections to or Sexual abuse includes threatened sexual abuse.

2 A: Identification of a child: Renville County Human Services Child Protection Services Mandated Reporter Form Name: Age or Date of Birth: Sex: Male Female Caretaker responsible for his/her care: Name: Relationship: Are there other children in the home? Telephone #: Employment: B: Identification of alleged perpetrator: Name: Telephone #: Relationship: C: Identification of person making report: Name: Telephone #: Relationship to child: Name of Facility: Date and Time of Report: 2 P a g e

3 D: Statement of the circumstances of the alleged abuse or neglect of child (who, what, where, when, how), be specific: E: Description of injuries or condition: (Diagram physical injuries) 3 P a g e

4 F: Any information/evidence regarding any previous injuries, neglect, or abuse: G. Is the child in any present danger? If so, please elaborate: H. What steps have been taken to prevent any further abuse/neglect? I: Any additional information, school attended? Daycare attended? Date: Time: J: Strength focused questions to ask for Children s Services intakes: How long has this been going on? 4 P a g e

5 What do you think is going well for this family? Do you know of any resources or supports that the family currently has? (i.e. extended family, people that stop by, people the children visit frequently, etc.) Do you know of any other supports or services that would be helpful to this family? What are you willing or able to do to help the family? Signature: Renville County Human Services Social Service INTAKE line Fax Attn: Child Protection Intake 5 P a g e

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