Dhs 3200 Template

Dhs 3200 Template

The DHS 3200 form is a critical document used to report actual or suspected child abuse or neglect in Michigan. This form serves as the written follow-up to an oral report made to the Department of Human Services and must be submitted to Centralized Intake for further investigation. If you suspect a child is being harmed, it is essential to fill out this form promptly by clicking the button below.

Table of Contents

The Dhs 3200 form is a crucial document used in Michigan for reporting actual or suspected child abuse or neglect. Designed for ease of use, it guides individuals through the reporting process with clear instructions. The form requires the reporting person to provide essential information about the child or children suspected of being abused or neglected, including their names, birth dates, and addresses. It also asks for details about the alleged perpetrator, their relationship to the child, and the circumstances surrounding the suspected abuse or neglect. Additionally, it includes sections for medical personnel to document findings from physical examinations, ensuring that all relevant medical information is considered. Understanding how to properly fill out this form is vital for anyone involved in the care or education of children, as it helps to protect vulnerable individuals and ensure that appropriate actions are taken. Furthermore, the form emphasizes the importance of confidentiality and the need for accurate reporting to the Centralized Intake for Abuse & Neglect.

Dhs 3200 Sample

DHS-3200 (Rev. 10-12) Previous edition may be used. MS Word 1
REPORT OF ACTUAL OR SUSPECTED CHILD ABUSE OR NEGLECT
Michigan Department of Human Services
Was com
p
laint
p
honed to DHS?
Yes
No
If yes, Log #
If no, contact Centralized Intake (855-444-3911) immediately
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.
1. Date
2. List of child(ren) suspected of being abused or neglected (Attach additional sheets if necessary)
NAME BIRTH DATE SOCIAL SECURITY
#
SEX RACE
3. Mother’s name
4. Father’s name
5. Child(ren)’s address (No. & Street)
6. City
7. County 8. Phone No.
9. Name of alleged perpetrator of abuse or neglect 10. Relationship to child(ren)
11. Person(s) the child(ren) living with when abuse/neglect occurred 12. Address, City & Zip Code where abuse/neglect occurred
13. Describe in
j
ur
y
or conditions and reason for sus
p
icion of abuse or ne
g
lect
14. Source of Com
p
laint
(
Add re
p
orter 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 Report Code (see above) 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 Report Code (see above) 17a. Name of reporting organization (school, hospital, etc.)
17b. Address (No. & Street) 17c. City 17d. State 17e. Zip Code 17f. Phone No.
18. Reporting person’s name Report Code (see above) 18a. Name of reporting organization (school, hospital, etc.)
18b. Address (No. & Street) 18c. City 18d. State 18e. Zip Code 18f. Phone No.
19. Reporting person’s name Report Code (see above) 19a. Name of reporting organization (school, hospital, etc.)
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 2
TO BE COMPLETED BY MEDICAL PERSONNEL WHEN PHYSICAL EXAMINATION HAS BEEN DONE
20. Summar
y
re
ort and conclusions of
p
h
y
sical 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
because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual
orientation, gender identity or expression, political beliefs or disability. If you need help with
reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make
y
our needs known to a DHS office in
y
our area.
AUTHORITY: P.A. 238 of 1975.
COMPLETION: Mandatory.
PENALTY: None.
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 28
th
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
OR
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.
▼ Dhs 3200 PDF Form

Document Attributes

Fact Name Description
Purpose The DHS-3200 form is designed for reporting actual or suspected child abuse or neglect in Michigan.
Governing Law This form is governed by the Child Protection Law, specifically P.A. 238 of 1975, as amended.
Mandatory Completion Filling out this form is mandatory for reporting suspected child abuse or neglect, ensuring that necessary information is provided to authorities.
Submission Method The completed form can be mailed, faxed, or emailed to the Centralized Intake for Abuse & Neglect in Michigan.

Dhs 3200: Usage Instruction

Filling out the Dhs 3200 form is an important step in reporting suspected child abuse or neglect. After completing the form, it needs to be sent to Centralized Intake for further processing. Make sure all information is accurate and detailed to ensure the report is taken seriously.

  1. Enter the date on which you are completing the form.
  2. List the child(ren) suspected of being abused or neglected. Provide as much information as possible.
  3. Fill in the mother’s name (or mother substitute) and any other relevant information.
  4. Fill in the father’s name (or father substitute) and any other relevant information.
  5. Enter the child(ren)’s address, including street number and name.
  6. Provide the city where the child(ren) reside.
  7. Enter the phone number of the household where the child(ren) live.
  8. Indicate the name of the alleged perpetrator of abuse or neglect.
  9. Specify the relationship of the alleged perpetrator to the child(ren).
  10. List the names of the person(s) the child(ren) were living with when the abuse or neglect occurred.
  11. Provide the address where the abuse or neglect occurred, including city and zip code.
  12. Describe the injury or conditions that led to the suspicion of abuse or neglect.
  13. Indicate the source of the complaint by checking the appropriate box for the reporting category.
  14. Fill in the reporting person’s name and contact details, including organization name if applicable.
  15. Repeat the above step for additional reporting persons if necessary, up to five times.
  16. If applicable, medical personnel should complete items 20-28, including summary reports and any lab results.
  17. Mail, fax, or email the completed form to Centralized Intake for Abuse & Neglect.

Frequently Asked Questions

  1. 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 abuse or neglect, and the individuals reporting the situation.

  2. Who should complete the DHS-3200 form?

    The reporting person, who may be a concerned individual or a professional such as a teacher, doctor, or social worker, should complete items 1-19 on the form. If medical personnel have conducted a physical examination, they are responsible for filling out items 20-28. It is crucial to provide as much detail as possible to ensure proper investigation and support for the child.

  3. How do I submit the DHS-3200 form?

    You can submit the completed form in several ways:

    • Mail it to: Centralized Intake for Abuse & Neglect, 5321 28th Street Court S.E., Grand Rapids, MI 49546.
    • Fax it to one of the following numbers: 616-977-8900, 616-977-8050, 616-977-1158, or 616-977-1154.
    • Email it to: DHS-CPS-CIGroup@michigan.gov.

    Be sure to keep a copy of the submitted form for your records.

  4. What information is required on the form?

    The form requires various details, including:

    • The names and birth dates of the child or children suspected of abuse or neglect.
    • The names of the parents or guardians.
    • The address and phone number of the child or children.
    • A description of the suspected abuse or neglect, including any injuries or conditions observed.
    • The name and relationship of the alleged perpetrator to the child or children.

    Providing comprehensive information helps facilitate a thorough investigation by the appropriate authorities.

Common mistakes

Filling out the DHS 3200 form can be a critical step in reporting suspected child abuse or neglect. However, there are common mistakes that can hinder the process. One mistake is failing to provide the correct date on the form. The date should reflect when the report is completed, not when the incident occurred. This detail is essential for tracking and processing the report.

Another frequent error involves incomplete information about the child. It is vital to list all children suspected of being abused or neglected, including their names, birth dates, and other relevant details. Omitting any child can lead to gaps in the investigation. Additionally, not indicating if a child has a disability that may require accommodation can further complicate matters.

Many individuals also overlook the importance of providing accurate information about the alleged perpetrator. The name and relationship to the child must be clearly stated. If this information is missing or incorrect, it can delay the response from authorities. Furthermore, failing to describe the injury or conditions that raised suspicion can weaken the report. Clear descriptions help investigators understand the severity of the situation.

Another common mistake is neglecting to fill out the source of the complaint correctly. Selecting the appropriate category is crucial, as it helps the authorities assess the situation based on the reporter's professional background. This can influence the urgency and type of response initiated.

In some cases, people forget to provide their contact information. The reporting person's name, organization, and phone number should be included to facilitate follow-up. This information is essential for any additional inquiries or clarifications that may arise during the investigation.

Additionally, individuals may not attach necessary documentation when required. For example, if medical personnel are involved, they must complete the relevant sections of the form. Failing to include these details can lead to delays in processing the report.

Lastly, not mailing the form to the correct address can result in significant delays. Ensuring the form is sent to Centralized Intake for Abuse & Neglect is crucial for prompt action. Individuals should double-check the address and consider alternative methods, such as fax or email, if necessary.

Documents used along the form

The DHS 3200 form is a critical document used for reporting suspected child abuse or neglect in Michigan. However, several other forms and documents often accompany it to ensure a comprehensive response to the situation. Below is a list of these documents, each serving a specific purpose in the reporting and investigation process.

  • Child Protection Investigation Report: This report is completed by Child Protective Services (CPS) after they investigate a report of abuse or neglect. It details the findings of the investigation and any actions taken.
  • Medical Examination Report: When a child has undergone a physical examination due to suspected abuse, this report provides medical professionals' observations and conclusions, which are crucial for understanding the child's condition.
  • Incident Report: This document is often created by schools or organizations when an incident occurs. It outlines the specifics of the event, including the parties involved and any immediate actions taken.
  • Referral for Services: If the investigation reveals that the child or family needs support services, this referral document is used to connect them with appropriate resources, such as counseling or therapy.
  • Safety Plan: In cases where a child may remain in the home, a safety plan outlines the steps that will be taken to ensure the child's safety. It may include supervision requirements or temporary relocation of the child.
  • Follow-Up Report: After the initial investigation, this report is generated to monitor the ongoing situation. It assesses the effectiveness of any interventions and the child's well-being over time.

Understanding these accompanying documents can enhance the reporting process and ensure that children receive the protection and support they need. Each document plays a vital role in safeguarding the welfare of children and addressing the complexities of abuse and neglect cases.

Similar forms

The DHS 3200 form is essential for reporting suspected child abuse or neglect. It shares similarities with several other documents used in similar contexts. Below is a list of six documents that are comparable to the DHS 3200 form, along with a brief explanation of how they are similar.

  • Child Protective Services (CPS) Report: Like the DHS 3200, this report is used to document allegations of child abuse or neglect. It requires detailed information about the child, the alleged perpetrator, and the nature of the abuse or neglect.
  • Incident Report Form: This form is utilized in various organizations to report incidents that may involve harm or risk to individuals. It similarly captures essential details about the event, including who was involved and the circumstances surrounding it.
  • Mandatory Reporting Form: This document is used by professionals required to report suspected abuse or neglect. It aligns with the DHS 3200 in terms of the information collected and the obligation to report findings to the appropriate authorities.
  • Medical Examination Report: When physical examinations are conducted following suspected abuse, this report is completed by medical personnel. It parallels the DHS 3200 in that it includes findings related to injuries and suspected abuse.
  • School Incident Report: Schools often have their own forms for reporting incidents involving students, including suspected abuse. These reports share a similar structure, requiring detailed accounts of the incident and the individuals involved.
  • Law Enforcement Report: When law enforcement is involved in cases of suspected abuse or neglect, officers complete reports that document their findings. These reports are similar in purpose and content, focusing on the details of the case and the individuals involved.

Dos and Don'ts

When filling out the DHS 3200 form, it’s important to follow specific guidelines to ensure accurate and effective reporting. Here are seven things you should and shouldn't do:

  • Do provide complete and accurate information for all required fields.
  • Do include the date the form is being completed at the top of the document.
  • Do describe the injury or conditions clearly, providing as much detail as possible.
  • Do check the appropriate source of complaint, ensuring it reflects the reporting individual’s profession.
  • Do attach additional sheets if necessary to include all relevant information about the child(ren).
  • Don't leave any mandatory fields blank; this may delay the processing of the report.
  • Don't include personal opinions or assumptions; stick to the facts as you know them.

Following these guidelines will help ensure that the form is completed correctly and efficiently, allowing for a timely response to the report of suspected abuse or neglect.

Misconceptions

  • Misconception 1: The Dhs 3200 form is only for medical professionals.

    • This form can be completed by anyone who suspects child abuse or neglect, not just medical personnel. While medical professionals fill out specific sections, the initial report can be made by teachers, social workers, or any concerned individual.

  • Misconception 2: Completing the form guarantees that action will be taken.

    • Filing the Dhs 3200 form does not automatically ensure intervention. The form serves as a report, and it is up to the Department of Human Services to investigate the claims further.

  • Misconception 3: The reporting person’s identity is always kept confidential.

    • While there are protections for the identity of the reporter, there are circumstances where it may be disclosed, especially if required for legal proceedings.

  • Misconception 4: The form must be filled out in one sitting.

    • The form can be completed over multiple sittings. It is important to gather accurate information, and taking the time to do so can be beneficial.

  • Misconception 5: Only physical signs of abuse need to be reported.

    • Both physical and emotional signs of abuse or neglect can be reported. The form allows for descriptions of various types of harm, including psychological abuse.

  • Misconception 6: The Dhs 3200 form is optional.

    • Filing the form is a mandatory step following an oral report of suspected child abuse or neglect, as required by Michigan law.

  • Misconception 7: Reports can be made anonymously without any follow-up.

    • While reports can be made anonymously, providing contact information can facilitate follow-up questions and ensure a thorough investigation.

  • Misconception 8: The Dhs 3200 form is only for children in immediate danger.

    • The form can be used for any suspicion of abuse or neglect, regardless of whether the child is in immediate danger. Early reporting can help prevent further harm.

  • Misconception 9: The form must be sent by mail only.

    • The Dhs 3200 form can be submitted via fax or email, providing multiple options for reporting suspected abuse or neglect.

  • Misconception 10: Completing the form is a one-time process.

    • In some cases, additional information may be required after the initial report. Follow-up communication may occur to gather further details or clarify the report.

Key takeaways

Understanding the Dhs 3200 Form is essential for reporting suspected child abuse or neglect. Here are four key takeaways to keep in mind:

  • The form must be completed as a follow-up to an oral report. Ensure that you indicate whether the report was phoned into the Department of Human Services (DHS).
  • Items 1-19 should be filled out by the reporting person, while items 20-28 are reserved for medical personnel if applicable.
  • Provide as much detail as possible about the child(ren) involved, including names, addresses, and any known disabilities that may require accommodations.
  • Submit the completed form to Centralized Intake via mail, fax, or email, ensuring that all information is accurate and complete to facilitate a timely response.