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Carlton County Human Services - Suspected Child Maltreatment Report

  1. CARLTON COUNTY CHILD MALTREATMENT REPORT
  2. Are you a Mandated Reporter?
  3. Are you a Voluntary Reporter?
  4. Have you made a verbal report to an Intake Worker?
  5. *Mandated Reporters are required to submit a written report within 72 hours, excluding holidays and weekends. [minn-stat.260E.091a]
  6. REPORTER INFORMATION
  7. Anonymous - (please note mandated reporters may not choose to remain anonymous)

  8. Mandated Reporter Agency Mailing Address (if applicable)
  9. IDENTIFYING INFORMATION OF ALLEGED VICTIM(S)
  10. Do you know or have reason to believe that the Child/Children have American Indian/Tribal Hertage?
  11. PERSON(S) BELIEVED TO BE RESPONSIBLE FOR THE ABUSE OR NEGLECT
  12. Gender
  13. INCIDENT REPORT
  14. Does the Person believed to be responsible for the abuse or neglect have access to the child(ren)?
  15. Please be aware that you will be contacted for a verbal report to ensure we have all the information needed to make an appropriate screening decision.
  16. Leave This Blank:

  17. This field is not part of the form submission.