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The Dhs 3200 form serves as a critical tool for reporting actual or suspected child abuse or neglect in Michigan. Designed by the Michigan Department of Human Services, this form is essential for ensuring that concerns about a child's safety are documented and addressed promptly. The reporting process begins with determining whether the complaint has already been communicated to the Department of Human Services (DHS) via phone. If not, immediate contact with Centralized Intake is necessary. The form requires detailed information about the child or children involved, including their names, birth dates, and addresses, as well as specifics about the alleged perpetrator and the nature of the suspected abuse or neglect. It also prompts the reporting individual to provide context, such as the source of the complaint and any relevant medical history if applicable. The latter sections of the form are reserved for medical professionals who may need to document findings from physical examinations or other medical assessments. Overall, the Dhs 3200 form is a vital step in protecting vulnerable children and ensuring that appropriate actions are taken to address any potential harm.

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 [email protected]

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
Click for Dhs 3200 File

File Breakdown

Fact Name Details
Purpose The DHS-3200 form is used to report actual or suspected child abuse or neglect in Michigan.
Mandatory Completion Filling out this form is mandatory as a follow-up to an oral report, as required by Michigan law.
Governing Law This form is governed by P.A. 238 of 1975, which mandates the reporting of child abuse and neglect.
Submission Methods The completed form can be mailed, faxed, or emailed to the Centralized Intake for Abuse & Neglect.
Reporting Process Sections 1-19 must be completed by the reporting person, while medical personnel complete sections 20-28 if applicable.

Guide to Using Dhs 3200

Filling out the Dhs 3200 form is an important step in reporting suspected child abuse or neglect. After completing the form, it should be sent to the Centralized Intake for Abuse & Neglect. This process ensures that the necessary authorities can investigate and take appropriate action.

  1. Enter the date the form is being completed in the first field.
  2. List the child(ren) suspected of being abused or neglected. Include their names, birth dates, social security numbers, sex, and race. If needed, attach additional sheets.
  3. Provide the mother’s name and any other relevant information.
  4. Provide the father’s name and any other relevant information.
  5. Enter the child(ren)’s address, including the street number and name.
  6. Input the city where the child(ren) live.
  7. Enter the phone number of the household where the child(ren) reside.
  8. Indicate the name of the alleged perpetrator of the abuse or neglect.
  9. Specify the relationship of the alleged perpetrator to the child(ren), such as parent or babysitter.
  10. List the names of the person(s) the child(ren) were living with when the abuse or neglect occurred.
  11. Provide the address, city, and zip code where the abuse or neglect occurred.
  12. Describe the injury or conditions that raised suspicion of abuse or neglect, including any relevant details.
  13. Identify the source of the complaint by checking the appropriate box for the reporting professional or organization.
  14. Enter the reporting person’s name and contact information, including organization name, address, and phone number. Repeat this for up to five reporting individuals if necessary.
  15. If applicable, medical personnel should complete items 20-28, including summaries of physical examinations and any relevant medical documentation.

After completing all required fields, send the form to the specified address, or consider faxing or emailing it as outlined in the instructions. Make sure to keep a copy for your records.

Get Answers on Dhs 3200

What is the purpose of the Dhs 3200 form?

The Dhs 3200 form is designed to report actual or suspected child abuse or neglect in Michigan. It serves as a written follow-up to an oral report made to the Department of Human Services (DHS). This form collects essential information about the child or children suspected of being abused or neglected, the alleged perpetrator, and the circumstances surrounding the situation. By completing this form, individuals can ensure that the appropriate authorities are notified, allowing for timely intervention and support.

Who is required to complete the Dhs 3200 form?

The form must be completed by the reporting person, who can be anyone with knowledge of the suspected abuse or neglect. This may include parents, teachers, medical professionals, or social workers. Items 1-19 should be filled out by the reporting person, while medical personnel are responsible for completing items 20-28 if a physical examination has been conducted. It is crucial that the form is filled out as completely as possible to provide accurate information to the authorities.

How should the Dhs 3200 form be submitted?

Once the form is completed, it must be submitted to the Centralized Intake for Abuse & Neglect. There are several ways to do this:

  1. Mail the form to: Centralized Intake for Abuse & Neglect, 5321 28th Street Court S.E., Grand Rapids, MI 49546.
  2. Fax the form to one of the following numbers: 616-977-8900, 616-977-8050, 616-977-1158, or 616-977-1154.
  3. Email the form to: [email protected].

It is important to choose a submission method that ensures the form reaches the appropriate department promptly.

What information is necessary to complete the Dhs 3200 form?

To complete the Dhs 3200 form, the following information is typically required:

  • The date the report is being completed.
  • Details about the child or children suspected of abuse or neglect, including names, birth dates, and social security numbers.
  • Information about the parents or guardians, including their names and addresses.
  • The name of the alleged perpetrator and their relationship to the child.
  • A description of the injuries or conditions that raised suspicion of abuse or neglect.
  • The source of the complaint, such as a teacher, doctor, or social worker.

Providing as much detail as possible will assist the authorities in their investigation and response.

Common mistakes

Filling out the Dhs 3200 form can be a daunting task, especially given the sensitive nature of the information being reported. One common mistake is failing to provide complete information about the child or children suspected of being abused or neglected. Incomplete entries can lead to delays in response or even miscommunication regarding the child's needs. It is crucial to ensure that all relevant details, such as names, birth dates, and addresses, are accurately filled out.

Another frequent error involves neglecting to specify the relationship of the alleged perpetrator to the child. This information is vital for investigators to understand the context of the situation. Without it, the report may lack clarity, which could hinder the investigation process. Additionally, individuals often overlook the importance of detailing the circumstances surrounding the abuse or neglect. A vague description may not provide the necessary insight for authorities to take appropriate action.

People sometimes skip the section that asks if the report was phoned into the Department of Human Services (DHS). This step is essential, as it helps track the report's origin and ensures that the appropriate log number is assigned. Without this information, the report may not be processed correctly. Furthermore, failing to provide contact information for the reporting person can lead to complications. Authorities may need to reach out for further details, and without a phone number or address, this becomes impossible.

Another common oversight is not indicating whether the child has a disability that may require accommodations. This information is critical for ensuring that the child receives the necessary support throughout the investigation. Additionally, some individuals mistakenly assume that medical personnel will complete the medical sections of the form. However, if medical professionals are not involved, the reporting person must ensure that all relevant information is provided.

Lastly, many individuals forget to sign and date the form. This final step is crucial, as it verifies that the report is legitimate and that the information provided is accurate to the best of the reporter's knowledge. Without a signature, the form may not be accepted, which could delay critical intervention for the child. By being aware of these common mistakes, individuals can help ensure that their reports are complete and effective in protecting children from abuse and neglect.

Documents used along the form

When filing the Dhs 3200 form, there are several other documents that may be necessary to support the report of suspected child abuse or neglect. Each document serves a specific purpose and helps ensure that all relevant information is gathered and submitted properly. Below is a list of these forms and documents, along with a brief description of each.

  • Medical Examination Report: This document provides details from a physical examination of the child, including any injuries or conditions observed. It is crucial for substantiating claims of abuse or neglect.
  • Laboratory Reports: These reports include results from any medical tests performed on the child. They can help identify signs of abuse or neglect that may not be visible during a physical examination.
  • X-Ray Results: X-ray images may reveal physical injuries that support allegations of abuse. This document is often included with the medical examination report.
  • Previous Medical Records: Accessing past medical records can provide insight into any history of abuse or neglect. This information can be vital in understanding the child’s current condition.
  • Witness Statements: Statements from individuals who may have witnessed the abuse or neglect can provide additional context and support for the report. These can include friends, family members, or professionals.
  • Incident Reports: If law enforcement or child protective services have been involved, their reports can provide critical information about the circumstances surrounding the allegations.
  • School Records: Records from the child’s school can show attendance, behavioral issues, or any other relevant information that may indicate neglect or abuse.
  • Referral Forms: If the case is being referred to another agency or service, these forms will outline the reasons for the referral and the services needed for the child.

Gathering these documents can help ensure that the report is thorough and provides a complete picture of the situation. It is important to approach this process with care, as the well-being of the child is the top priority. If you have any questions or need assistance, there are resources available to help you navigate this process.

Similar forms

The DHS 3200 form is a crucial document for reporting suspected child abuse or neglect. Several other forms serve similar purposes in different contexts, each designed to facilitate the reporting and documentation of such serious matters. Here’s a list of seven documents that share similarities with the DHS 3200 form:

  • Child Protective Services Report Form: This form is used by various states to report suspected child abuse or neglect. Like the DHS 3200, it collects detailed information about the child, the alleged perpetrator, and the circumstances surrounding the report.
  • Incident Report Form: Often used in schools or childcare settings, this form documents incidents involving children. It captures details about the event, similar to how the DHS 3200 gathers information on suspected abuse or neglect.
  • Mandatory Reporting Form: Many professions, such as healthcare and education, have specific forms for mandatory reporting of abuse. These forms require the reporter to provide information about the child and the suspected abuse, mirroring the structure of the DHS 3200.
  • Domestic Violence Report Form: This form is designed for reporting instances of domestic violence, particularly when children are involved. It collects information on the victim, the perpetrator, and the nature of the abuse, akin to the DHS 3200’s focus on child welfare.
  • Adult Protective Services Report Form: Similar to the DHS 3200, this form is used to report suspected abuse or neglect of vulnerable adults. It gathers information about the adult in question and the suspected abuser, reflecting the same principles of protection and documentation.
  • School Incident Reporting Form: Schools often use this form to report incidents involving students, including abuse or neglect. It requires detailed descriptions and is structured similarly to the DHS 3200, focusing on the individuals involved and the nature of the incident.
  • Health Care Provider Reporting Form: This form is utilized by medical professionals to report suspected abuse or neglect. It requires comprehensive details about the patient and the suspected abuse, paralleling the DHS 3200’s emphasis on thorough reporting.

Each of these documents plays a vital role in ensuring the safety and well-being of children and vulnerable individuals. They help create a structured process for reporting and responding to abuse, fostering a safer environment for all.

Dos and Don'ts

When filling out the Dhs 3200 form, it is essential to approach the task with care and attention to detail. Here is a list of things you should and shouldn't do to ensure the process goes smoothly.

  • Do read the instructions thoroughly before starting.
  • Do provide complete and accurate information for each section.
  • Do include all necessary details about the child(ren) involved.
  • Do ensure that the report is sent to the correct address.
  • Do keep a copy of the completed form for your records.
  • Don't leave any required fields blank; fill in all applicable information.
  • Don't use jargon or unclear language that may confuse the reader.
  • Don't submit the form without reviewing it for errors or omissions.
  • Don't hesitate to ask for help if you have questions about the process.

Completing the Dhs 3200 form is a serious responsibility, and taking the time to follow these guidelines can make a significant difference in the outcome. Your diligence and care in this process can help ensure that children receive the protection and support they need.

Misconceptions

Misconceptions about the DHS 3200 form can lead to confusion and delays in reporting suspected child abuse or neglect. Here are seven common misunderstandings:

  • Only professionals can report suspected abuse. Anyone can report suspected child abuse or neglect. While professionals are encouraged to report, concerned individuals should also take action.
  • The form must be filled out perfectly. While accuracy is important, incomplete forms can still be submitted. It’s better to report any suspicion than to wait for perfect information.
  • Reports are anonymous. While the identity of the reporter is kept confidential, it may be disclosed in certain circumstances, such as court proceedings.
  • Submitting the form is the only step needed. Reporting suspected abuse is just the beginning. Follow-up actions may be required, and it’s crucial to remain available for any additional information.
  • The form can be submitted anywhere. The DHS 3200 form must be sent specifically to Centralized Intake. It cannot be submitted to other agencies or locations.
  • Only physical abuse needs to be reported. Neglect and emotional abuse are also valid reasons for filing a report. All forms of suspected abuse or neglect should be reported.
  • There are penalties for false reporting. While making a false report is serious, good faith reports made with genuine concern for a child’s safety are protected. It’s better to err on the side of caution.

Understanding these misconceptions can help ensure that concerns about child welfare are addressed promptly and appropriately.

Key takeaways

When filling out the Dhs 3200 form, it’s crucial to pay attention to detail. Here are some key takeaways to ensure the process goes smoothly:

  • Complete All Required Sections: Ensure that items 1-19 are filled out completely by the reporting person. Items 20-28 should only be completed by medical personnel if applicable.
  • Provide Accurate Information: Include correct names, addresses, and dates. This information is vital for the investigation.
  • Indicate Any Disabilities: If the child or any involved adult has a disability that may require accommodations, make sure to note this on the form.
  • Log Number: If the report was made by phone, include the Log # if known. This helps track the report through the system.
  • Describe the Situation Clearly: In section 13, provide a detailed description of the injury or conditions that led to the suspicion of abuse or neglect.
  • Source of Complaint: Accurately check the appropriate box for the source of the complaint in section 14. This helps categorize the report correctly.
  • Submission Options: After completing the form, you can mail, fax, or email it to Centralized Intake. Choose the method that works best for you.
  • Mandatory Completion: Remember, completing this form is mandatory. Ensure it is filled out thoroughly to avoid delays in processing.

By following these guidelines, you can help ensure that reports of suspected child abuse or neglect are handled effectively and efficiently.