The DHS 3200 form is an essential document designed by the Michigan Department of Human Services for the reporting of actual or suspected child abuse or neglect. This detailed form requires the reporter to provide comprehensive information, including personal details about the child or children involved, the nature of the alleged abuse or neglect, and the identity of the suspected perpetrator(s), among other critical data. For all concerned individuals, it's imperative to fill out and submit this form accurately to ensure the safety and well-being of children. To complete the DHS 3200 form, click the button below.
In the realm of child welfare, rigorous documentation and procedural adherence are critical for safeguarding vulnerable children. The DHS 3200 form, a crucial document issued by the Michigan Department of Human Services, materializes as a formal report of actual or suspected child abuse or neglect. The essence of this document lies not only in initiating the procedural response to potential child welfare concerns but also in ensuring that such concerns are systematically recorded and addressed. This form serves as a written follow-up to any oral reports previously made to DHS, encapsulating detailed information to aid in the assessment and intervention tasks undertaken by child protective services. The DHS 3200 requires informants to meticulously document a range of information, including but not limited to, the child's personal details, the parent or guardian's information, specifics of the alleged abuser, and the nature of the abuse or neglect suspected. Designed to be comprehensive, the form includes sections exclusive to medical personnel, thereby integrating medical assessments into the child's welfare report. Furthermore, it embodies a commitment to non-discrimination and accessibility, explicitly stating support for individuals with disabilities and underscoring the legal mandate underpinning its completion. This document, reflecting a structured approach to child welfare reporting, stands as a testament to procedural precision aimed at protecting children from harm.
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
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
17a. Name of reporting
17b. Address (No. & Street)
17c. City
17d. State
17e. Zip Code
17f. Phone No.
18. Reporting person’s name
18a. Name of reporting
18b. Address (No. & Street)
18c. City
18d. State
18e. Zip Code
18f. Phone No.
19. Reporting person’s name
19a. Name of reporting
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
1
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
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.
2
Filing a report of actual or suspected child abuse or neglect is a significant step in ensuring the safety and well-being of a child. The DHS 3200 form is designed for this purpose in the state of Michigan. This form requires thorough details about the child, the nature of the alleged abuse or neglect, and information about the reporter. It is mandatory for individuals who suspect child abuse or neglect to complete and submit this form accurately to the Department of Human Services (DHS), ensuring prompt action can be taken to protect the child. Below are detailed steps to accurately complete and submit the DHS 3200 form.
Once you have filled out the form, make sure to review your information for accuracy. The completed form should be mailed or faxed to Centralized Intake for Abuse & Neglect, with the contact details provided in the form instructions. Email submission is also an option. Ensuring the form is filled out comprehensively and submitted promptly will facilitate a quicker response and necessary interventions to safeguard the child or children involved.
The DHS 3200 form is designed for the reporting of actual or suspected child abuse or neglect in Michigan. It serves as a written follow-up to any oral report made to the Department of Human Services (DHS), as required by the law. This detailed form ensures that all relevant information about the suspected abuse or neglect, including details about the child, the reporter, the alleged perpetrator, and the specific concerns, is formally documented and sent to DHS's Centralized Intake for Abuse & Neglect for further action.
The initial sections of the DHS 3200 form (items 1-19) are to be filled out by the person reporting the suspected abuse or neglect. This can include a wide range of professionals such as teachers, healthcare providers, social workers, and law enforcement officers, among others. Additionally, any individual who has reason to believe that a child is being abused or neglected is encouraged to complete this form. Items 20-28 of the form are specifically reserved for medical personnel who have conducted a physical examination of the child in question.
The completed DHS 3200 form can be submitted through various methods:
After the DHS 3200 form is submitted, the Centralized Intake for Abuse & Neglect reviews the information provided. If the report is deemed to meet the criteria for suspected abuse or neglect, the case is forwarded to the appropriate local office for investigation. DHS staff may contact the reporting person for additional information if needed. The primary goal after submission is to assess the situation and implement measures to ensure the child's safety and well-being.
When completing the DHS 3200 form, a document crucial for reporting actual or suspected child abuse or neglect in Michigan, individuals frequently make errors that can hinder the process. Understanding these mistakes can significantly enhance the accuracy and effectiveness of reporting, ensuring that the necessary actions are taken promptly to safeguard the well-being of children.
These frequent mistakes can delay the response time and affect the quality of the intervention provided to the child or children in question. Individuals tasked with filling out the DHS 3200 form should pay careful attention to every detail, provide as much information as possible, and follow all guidelines, including immediate verbal reporting to DHS’ Centralized Intake. Correct and thorough completion of the form can significantly contribute to the safety and well-being of children in the state of Michigan.
Completing the DHS 3200 form, "Report of Actual or Suspected Child Abuse or Neglect," is a critical step in ensuring the safety and well-being of children. However, this document is often just the starting point in the reporting and investigation process. Various other forms and documents might be required to provide a comprehensive overview of the situation, ensure that all necessary information is captured, and facilitate effective action.
Together, these documents enhance the information provided in the DHS 3200 form, creating a fuller picture of the child's circumstances and assisting those responsible for the investigation and intervention in making informed decisions. Ensuring the protection and welfare of children requires thorough documentation and a holistic view of each child's situation.
The Child and Family Services Reviews (CFSR) Reporting Data Form is similar to the DHS 3200 form in that both are used within child welfare agencies to report and document crucial information pertaining to the well-being of children. The CFSR form, specifically, collects information for assessing state performance in meeting the needs of families and children who come into contact with the child welfare system.
Intake Form for Child Protective Services (CPS) shares similarities with the DHS 3200 form, being another initial report document. This form typically gathers basic identifying information about the child, the nature of the alleged abuse or neglect, and the alleged perpetrator, which is essential for initiating an investigation.
The Family First Prevention Services Act (FFPSA) Data Collection Form parallels the DHS 3200 form in its focus on prevention efforts to avoid child abuse and neglect. Although the FFPSA form is more focused on systematic data collection to support families and prevent foster care placements, both forms serve the greater goal of child protection.
Health Information Form for Foster Care is similar in that it records detailed health-related information for children entering the foster care system, similar to how the DHS 3200 includes a section for medical personnel. Both forms ensure that relevant health data is collected and documented for the well-being of the child.
The Incident Report Form in Residential Facilities captures specifics around incidents involving children in care settings, including abuse and neglect, paralleling the DHS 3200’s function of documenting suspected or actual abuse or neglect cases, though it's specifically for incidents within institutional settings.
Adoption and Safe Families Act (ASFA) Compliance Form shares commonalities with the DHS 3200 form in its intent to protect children’s welfare. While the ASFA form is used to ensure timely adoption processes and check compliance with federal standards, both forms work towards the ultimate goal of ensuring child safety and securing a safe home environment.
The Emergency Medical Authorization Form for Minors is similar in terms of its focus on children's well-being, authorizing emergency medical treatment. Although its primary purpose is medical, like the medical section of the DHS 3200, it underscores the importance of addressing the immediate health needs of minors in potentially harmful situations.
School-Based Referral Form for Suspected Abuse/Neglect closely mirrors the DHS 3200 form. This document is often used by educators to report concerns about a child’s welfare, capturing much of the same information about suspected abuse or neglect situations and forwarding this information to child welfare agencies.
The Foster Care Placement Agreement, while primarily a contractual document between caregivers and child welfare agencies, shares the DHS 3200 form's underlying concern for child welfare, ensuring that foster placements are safe and conducive to the child's needs, including stipulations about reporting abuse or neglect.
The Substance Exposed Infants (SEI) Notification Form aligns with the DHS 3200 form in its specificity toward a particular issue—substance exposure in infants—offering a detailed protocol for reporting and documenting such cases to ensure the child receives appropriate care and services.
When completing the DHS 3200 form, which is essential for reporting actual or suspected child abuse or neglect in Michigan, certain practices should be followed while others avoided to ensure accurate and effective reporting. Here are the dos and don'ts to keep in mind:
Remember, accurately and completely filling out the DHS 3200 form is a critical step in protecting children from abuse and neglect. Your thoroughness and timeliness can make a substantial difference in a child's life.
When it comes to understanding the DHS 3200 form, commonly known as the "Report of Actual or Suspected Child Abuse or Neglect" in Michigan, a number of misconceptions frequently arise. It is crucial to clarify these misunderstandings to ensure that reports are filed correctly and efficiently, facilitating the protection of children in a timely manner. Here are five common misconceptions:
Understanding these key points about the DHS 3200 form can empower individuals to report activities efficiently and confidently. The primary objective is always the safety and well-being of the child, and clarity in the reporting process plays a vital role in this mission.
Filling out the DHS 3200 form is an essential step in reporting actual or suspected child abuse or neglect in Michigan. Its purpose is to ensure that the necessary details reach the right hands for further action. Below are key takeaways regarding the completion and usage of this form:
Accurate and thorough completion of the DHS 3200 form is crucial for the protection of children and the effectiveness of Michigan's child welfare services. It ensures a structured and standardized method for reporting suspected cases of child abuse or neglect, facilitating timely and appropriate interventions.
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