report of suspected child abuse or neglect

REPORT OF SUSPECTED CHILD ABUSE OR NEGLECT

NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES

CHILDREN AND FAMILY SERVICES

SFN 960 (7-2022)

Name of Child(ren) Age or Birthdate Name of Child(ren) Age or Birthdate

IDENTIFYING INFORMATION

Name of Parent(s)/Caretaker

Telephone Number

Address City

State

ZIP Code

Name of Subject (Person(s) Suspected to be Causing Maltreatment)

Telephone Number

Address City

State

ZIP Code

Give nature and extent of the suspected abuse or neglect, including any information of previous abuse or neglect; family

composition; and any other information which may be helpful in protecting the health and welfare of the child(ren). If

additional space is needed, attach additional pages. (BE SPECIFIC. ANSWER WHO, WHAT, WHEN, WHY, HOW

OFTEN).

Name of Reporter Reporter's Relationship to Children

Telephone Number

Address City

State

ZIP Code

Signature of Reporter Email Address

Date

AGENCY USE ONLY

Date and Time Received by Agency Name of Intake Social Worker Source

Date of Entry

Report Number Assessment Number Case Number

Name of Social Worker Assigned to Case

Received By

In Person Telephone Written

Initial Category

A B C

Please fax the completed form to the ND Child Protection Services Central Intake Unit at 701-328-0361 or submit to the

local county human service zone office where the child is currently physically located. Contact information for county human

service zone offices can be found at: www.nd.gov/dhs/locations/countysocialserv

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