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The Dhs 3200 form, officially titled the "Report of Actual or Suspected Child Abuse or Neglect," serves as a vital document for anyone seeking to report concerns regarding child welfare in Michigan. It provides a standardized way for reporting individuals to detail instances of potential abuse or neglect. The form begins by assessing whether the complaint was initially communicated to the Department of Human Services (DHS) by phone or not. If it was reported, the reporting individual must include the corresponding log number. Sections of the form require information about the child or children involved, their parents or guardians, and the alleged perpetrator. It also asks for key details about where and when the incident occurred and the specific concerns leading to the report. Moreover, the form addresses the roles of various professionals—such as physicians, teachers, and social workers—who may be involved in the reporting process. Another critical part of the document is reserved for medical professionals to document any physical examinations conducted, ensuring all relevant medical information is captured and considered. Lastly, it outlines submission instructions, including where to send the completed form, whether by mail, fax, or email, thereby streamlining the process for concerned individuals to ensure the safety and well-being of children.

Dhs 3200 Example

REPORT OF ACTUAL OR SUSPECTED CHILD ABUSE OR NEGLECT

Michigan Department of Human Services

Was complaint phoned to DHS?

If no, contact Centralized Intake (855-444-3911) immediately

Yes

No

If yes, Log #

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.

2. List of child(ren) suspected of being abused or neglected (Attach additional sheets if necessary)

1. Date

NAME

BIRTH DATE

SOCIAL SECURITY #

SEX

RACE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Mother’s name

 

 

 

 

 

 

 

 

 

 

 

 

4.

Father’s name

 

 

 

 

 

 

 

 

7. County

 

 

5.

Child(ren)’s address (No. & Street)

6. City

8. Phone No.

 

 

 

 

 

child(ren)

 

 

9.

Name of alleged perpetrator of abuse or neglect

10.

Relationship to

 

 

 

 

 

11. Person(s) the child(ren) living with when abuse/neglect occurred

12.

Address, City & Zip Code where abuse/neglect occurred

13.Describe injury or conditions and reason for suspicion of abuse or neglect

14.Source of Complaint (Add reporter 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

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TO BE COMPLETED BY MEDICAL PERSONNEL WHEN PHYSICAL EXAMINATION HAS BEEN DONE

20. Summary report and conclusions of physical 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

AUTHORITY:

P.A. 238 of 1975.

because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual

COMPLETION:

Mandatory.

orientation, gender identity or expression, political beliefs or disability. If you need help with

PENALTY:

None.

reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make

your needs known to a DHS office in your area.

 

 

 

 

 

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 28th 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 (Rev. 10-12) Previous edition may be used. MS Word

2
Get Dhs 3200 PDF Form

Form Characteristics

Fact Name Details
Form Title REPORT OF ACTUAL OR SUSPECTED CHILD ABUSE OR NEGLECT
Governing Authority P.A. 238 of 1975
Purpose of Form This form serves as a follow-up to the oral report of suspected child abuse or neglect.
Submission Method The completed form can be mailed, faxed, or emailed to Centralized Intake.
Responsible Department Michigan Department of Human Services (DHS)
Mandatory Completion Completion of the form is mandatory when reporting child abuse or neglect.
Who Completes It Items 1-19 are to be completed by the reporting person; medical personnel complete items 20-28.
Phone Reporting If the complaint was phoned to DHS, a Log Number should be recorded on the form.
Disability Accommodations Individuals needing assistance under the Americans with Disabilities Act are encouraged to notify a DHS office.

Guidelines on Utilizing Dhs 3200

Filling out the Dhs 3200 form can seem daunting at first, but it is a crucial step in reporting suspected child abuse or neglect. Taking your time to gather all the necessary information will ensure that the form is completed accurately. Once you have filled it out, you’ll be sending it to the Centralized Intake for further processing, which will help safeguard the well-being of the child or children involved.

  1. Enter the date: Fill in the date when you complete the form.
  2. List child(ren) suspected of being abused or neglected: Provide information about each child, including name, birth date, social security number, sex, and race. If necessary, attach additional sheets.
  3. Mother’s name: Write down the mother’s name (or that of a substitute) along with any additional details.
  4. Father’s name: Include the father’s name (or that of a substitute) and relevant information.
  5. Child(ren)’s address: Fill in the child's address, including street number and name.
  6. City: Specify the city where the child resides.
  7. County: Enter the county in which the child’s address is located.
  8. Phone number: Provide the phone number for the child’s residence.
  9. Alleged perpetrator’s name: Indicate the person suspected of abuse or neglect.
  10. Relationship to child(ren): Describe the relationship between the alleged perpetrator and the child(ren).
  11. Persons child(ren) were living with during the incident: List the names of individuals living with the child when the suspected abuse or neglect occurred.
  12. Address where abuse/neglect occurred: Provide the specific address where the incident took place.
  13. Describe injuries or conditions: Explain the injuries or conditions you observed and your reasons for suspecting abuse or neglect.
  14. Source of complaint: Check the appropriate box indicating who is making the report (e.g., school nurse, physician).
  15. Reporting person's information: Enter your name, organization name, address, and phone number as the reporter.
  16. Complete items for medical personnel (if applicable): If you are a medical professional, fill out sections regarding physical examination and medical documentation.

Once you complete all relevant fields, make sure to review your entries for accuracy. Then, mail, fax, or email the form to the Centralized Intake at the address or contact provided within the form instructions. Your diligence in this process is vital for the safety and protection of the child or children involved.

What You Should Know About This Form

What is the DHS 3200 form used for?

The DHS 3200 form is a report of actual or suspected child abuse or neglect. It allows individuals to provide information to the Michigan Department of Human Services (DHS) about concerns they have for a child’s safety. This form serves as a follow-up to any oral reports made to the DHS.

Who should fill out the DHS 3200 form?

Anyone who suspects child abuse or neglect can fill out the form, but the reporting person must complete sections 1-19. Medical professionals must complete sections 20-28 if they have conducted a physical examination related to the case.

How do I submit the DHS 3200 form?

You can mail the completed form to Centralized Intake for Abuse & Neglect at 5321 28th Street Court S.E., Grand Rapids, MI 49546. Alternatively, you can fax it to the specified numbers or email it to the provided DHS email address.

What information is required on the form?

You'll need to provide details about the child or children suspected of being abused or neglected, including names, birth dates, and addresses. Information about the alleged perpetrator, the nature of the allegations, and your contact information must also be included. Make sure to describe the injuries or conditions that raised your concern.

What if I'm not sure if my report qualifies as child abuse or neglect?

If you have any concerns about a child's welfare, it's always better to report. DHS encourages anyone unsure about the situation to err on the side of caution. The agency will handle the report and determine the next steps.

Are there any penalties for filing a false report?

The form notes that there is no penalty for reporting; however, filing a false report can lead to legal consequences for the individual making the report. It’s crucial to provide honest and accurate information.

What happens after I submit the DHS 3200 form?

Once submitted, the information will be reviewed by DHS. They will assess the situation and determine whether further investigation is necessary. You may be contacted for additional information if needed.

Can I remain anonymous when submitting a report?

You can submit your report anonymously. However, providing your contact information may help investigators follow up if they have additional questions or need clarification on the situation.

Common mistakes

When filling out the Dhs 3200 form, one common mistake is failing to include accurate and complete information for items 1 through 19. Omissions can lead to delays in the processing of the report and may result in inadequate action from authorities. Providing full names, addresses, and details is crucial for the entity reviewing the case.

Another frequent error involves neglecting to list all children suspected of abuse or neglect. If multiple children are involved, each one should be named with all relevant details provided. A lack of comprehensive information can hinder proper investigation efforts and might leave children at risk for further harm.

Individuals sometimes misidentify the alleged perpetrator, which can complicate investigations. It’s essential to provide the correct name and relationship to the child for accurate tracking of the case. Reporting the wrong name can divert attention away from the actual individual responsible for the situation.

Many people also fail to describe injuries or conditions thoroughly. This section needs detailed information about why abuse or neglect is suspected. Providing vague statements may not sufficiently convey the seriousness of the situation, thus impacting the urgency with which authorities respond.

Another oversight often made relates to filling out contact information for the reporting person. Many do not write their phone number or email correctly, which may hinder follow-up communication. Ensuring that contact details are absolutely correct allows for quicker resolution and decision-making.

Lastly, some individuals neglect to check the appropriate box indicating the source of the complaint. Proper categorization helps prioritized responses. Failing to do so may prevent the right professionals from engaging with the report in a timely manner. Each of these errors can significantly delay the help that a child in danger needs.

Documents used along the form

The DHS-3200 form, which serves as a report of actual or suspected child abuse or neglect, is often accompanied by several other documents to facilitate a thorough review of the situation. Each of these documents plays a crucial role in ensuring the safety and well-being of the child involved. It is essential to understand the purpose of each of these forms, as they are vital for proper reporting and subsequent action.

  • Medical Documentation: This includes any medical reports or evaluations provided by healthcare professionals. It assists in clarifying the child’s health status and any injuries or conditions related to suspected abuse.
  • Laboratory Reports: These reports contain results from any medical tests performed on the child. They may help identify potential physical evidence of abuse or neglect.
  • X-Ray Reports: When physical abuse is suspected, X-rays may be conducted to investigate for fractures or other internal injuries. The reports provide critical evidence regarding the child’s physical state.
  • Witness Statements: Collecting statements from individuals who may have witnessed the abuse or neglect can present additional context and support for the reported claims.
  • Prior Medical History: Documentation of previous hospitalizations or medical examinations for the child is important. It provides insight into any patterns of care or signs of past abuse.
  • Incident Reports: If law enforcement has been involved, incident reports might be created. These contain details of any investigations or actions taken at the time of the reported incident.
  • Social Worker Assessments: Assessments or reports from social workers involved with the family may offer valuable perspectives on the living conditions and the context surrounding the alleged abuse.
  • Child Protective Services (CPS) Reports: If previous reports have been made to CPS, any resultant case files or reports will be essential in assessing the child's safety history.
  • Referral Forms: If the case is referred to services outside of DHS, such as counseling or rehabilitation programs, these forms provide information about available resources for the family.

In summary, the DHS-3200 form acts as a key component in the child protection process, often necessitating the inclusion of multiple supporting documents. Each form aids in painting a comprehensive picture of the child's situation, helping authorities make informed decisions swiftly. Ensuring all necessary documentation is properly submitted can significantly impact the effectiveness of the intervention process and the safety of the child.

Similar forms

  • Child Protection Services (CPS) Report: Like the DHS 3200 form, a CPS report documents concerns about possible child abuse or neglect. Both require detailed information about the child, family dynamics, and the situation leading to the report.
  • Mandatory Reporting Form: This form is similar as it involves professionals reporting suspected abuse. Much like the DHS 3200, it mandates specific information to be collected and submitted promptly, ensuring thorough documentation.
  • Incident Report Form: Often used in schools or healthcare settings, this form captures the specifics of an incident involving a child. It shares similarities with the DHS 3200 by requiring detailed narratives about the situation and parties involved.
  • Adult Protective Services (APS) Report: While focused on vulnerable adults, an APS report shares the same structure in addressing concerns of abuse or neglect. Both forms gather critical details about the individuals involved, relationships, and observations leading to the report.

Dos and Don'ts

When filling out the Dhs 3200 form, certain practices can ensure a smoother process while avoiding common pitfalls. Here are ten things to consider:

  • Do provide clear and accurate information for each question.
  • Don't skip over any mandatory fields; incomplete forms can delay processing.
  • Do include additional sheets if more space is needed to describe the child(ren) suspected of abuse or neglect.
  • Don't include personal opinions or subjective language when describing incidents; stick to the facts.
  • Do double-check phone numbers and addresses to ensure they're correct.
  • Don't forget to note any disabilities of the child or family members that may require accommodation.
  • Do send the form via the preferred method listed (mail, fax, or email) to avoid complications later.
  • Don't assume prior submissions are available; always include new details relevant to the case.
  • Do keep a copy of the filled form for your records.
  • Don't wait to report; if you suspect abuse or neglect, act as soon as possible.

Following these guidelines can help ensure that the reporting process is efficient and effective.

Misconceptions

Misconceptions about the DHS 3200 form can cause confusion for individuals reporting suspected child abuse or neglect. Clarifying these misunderstandings is crucial for ensuring the safety and well-being of children. Below is a list of common misconceptions:

  • The DHS 3200 form is optional. Some people believe that completing the form is not necessary. In fact, it is mandatory to provide a written follow-up to any oral report of suspected abuse or neglect.
  • Only professionals can report abuse. Many think that only certain professionals can file this report. However, anyone who suspects child abuse or neglect can and should report it.
  • The report is confidential. While the identity of the reporting person is generally kept confidential, there are circumstances under which it may be disclosed during a legal proceeding.
  • The DHS 3200 form must be completed in person. Some individuals think the form must be filled out and submitted in person. This is not true—the form can be mailed, faxed, or emailed as indicated in the instructions.
  • All fields on the form must be filled out for it to be valid. Many people assume that every section must have information. If certain information is not available, it can be left blank as long as essential details are provided.
  • The form is only for immediate emergencies. Some believe the DHS 3200 form is only for urgent situations. In reality, it is meant for reporting all suspicions of abuse or neglect, regardless of the urgency.
  • Substantiated reports always lead to criminal charges. There is a misconception that a report being substantiated means criminal charges will automatically follow. While this can happen, it is not a guarantee.
  • The reporting person has to investigate the situation. Some individuals think they need to gather all facts before reporting. The responsibility of investigating lies with the Department of Human Services, not the reporting person.
  • Filing a report will make things worse for the child. Many fear that making a report could harm the child. In reality, reporting can help ensure the child receives the protection and support they need.
  • You can report anonymously. While anonymity is possible, providing one’s identity can help with follow-up and investigation, making the report more effective.

Understanding these misconceptions can empower individuals to take the necessary steps for the protection of children in their community.

Key takeaways

Key Takeaways for Using the DHS 3200 Form:

  • The DHS 3200 form is essential for reporting actual or suspected child abuse or neglect in Michigan.
  • Complete Items 1-19 accurately, ensuring to include all relevant details about the child or children involved, and the suspected perpetrator.
  • If the report was made over the phone, it is crucial to note the log number when filling out the form.
  • Items 20-28 should only be filled out by medical personnel if applicable, so be mindful of who is responsible for these sections.
  • Submit the completed form promptly to Centralized Intake via mail, fax, or email to ensure swift action in addressing the situation.

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