This form is to be used in conjunction with reports made in person or over the telephone by MANDATED REPORTERS. Please read the instructions before you fill out the form. For your convenience, this form may be completed online and printed.

To insure proper receipt of this information after submitting your verbal report, please DO NOT e-mail this form. Mail or fax this form directly to the appropriate County Department of Human Resources. You can find the contact information for your county office here.