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Protecting children from abuse and neglect is a cornerstone of a compassionate society. The DHS 3200 form, structured by the Michigan Department of Human Services, stands as a vital tool in this protective framework. Crafted with meticulous care, this form serves as both a report and a record for actual or suspected cases of child abuse or neglect. It embodies a procedural gateway, mandating an initial telephonic report to the DHS Centralized Intake, assuring a prompt response to emerging situations. This detailed document extends beyond mere reporting; it is an invitation for thorough documentation by the reporter through items 1-19, with a dedicated section for medical personnel to contribute findings in items 20-28. Whether it be the identification of the child involved, details of the alleged perpetrator, or the condition leading to suspicion, each item seeks comprehensive elucidation. This streamlined approach not only ensures that every suspicion of abuse or neglect is followed up with the gravity it warrants but also underscores the collaborative effort between community members and professionals in safeguarding the well-being of children. Integral to this endeavor is the commitment to non-discrimination and accessibility, ensuring that every child's case is given attention irrespective of any external factors, thereby upholding the principles of equity and justice.

Preview - Dhs 3200 Form

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

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

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
Download Dhs 3200 PDF Form

Form Data

Fact Name Description
Purpose of Form DHS-3200 Used for the written follow-up to an oral report of actual or suspected child abuse or neglect in Michigan.
Initial Contact Indicates whether the complaint was initially phoned into DHS and provides the number for Centralized Intake.
Information Required Reporting person must complete items 1-19 with detailed information on the child(ren), alleged perpetrator, and circumstances of the abuse or neglect.
Medical Personnel Section Items 20-28 are reserved for completion by medical personnel when a physical examination has been conducted.
Governing Law Operates under the authority of P.A. 238 of 1975, specifying mandatory reporting requirements in Michigan.
Non-Discrimination Policy The Department of Human Services will not discriminate against any individual or group based on factors including race, religion, or disability.

Instructions on Utilizing Dhs 3200

Filling out the DHS 3200 form is a critical step in reporting actual or suspected child abuse or neglect to the Michigan Department of Human Services. This process involves providing detailed information to ensure the report is handled properly and efficiently. The form is divided into sections that the reporting person and medical personnel (if applicable) need to complete. It is important to fill out this form as completely and accurately as possible, as it plays a vital role in protecting children's well-being. Below are the steps required to complete the DHS 3200 form.

  1. Enter the date the form is being completed.
  2. List the child(ren) suspected of being abused or neglected, including all available information such as name, birth date, social security number, sex, and race. Attach additional sheets if necessary.
  3. Provide the mother's name, or the mother substitute’s details, along with any other available information. Note any disabilities that may need accommodation.
  4. Fill in the father's name, or the father substitute’s details, and any additional relevant information. Indicate if accommodation for disabilities is required.
  5. Enter the child(ren)'s address, including number, street, city, and county.
  6. Specify the phone number of the household where the child(ren) resides.
  7. Identify the name of the alleged perpetrator of abuse or neglect.
  8. Clarify the relationship to the child(ren) of the alleged perpetrator.
  9. State the person(s) the child(ren) was living with when the abuse/neglect occurred. Include names and indicate if they have a disability requiring accommodation.
  10. Provide the address where the abuse/neglect occurred, including city and zip code.
  11. Detail the injury or conditions and reasons for suspicion of abuse or neglect in the described section.
  12. Select the source of the complaint by checking the appropriate box and indicating the report code from the provided list.
  13. For items 15 to 19, enter the reporting person’s name, organization (if applicable), and complete address information, including phone number.

For medical personnel completing the form, include details of any physical examinations, laboratory reports, x-rays, and other relevant medical information in sections 20 to 28.

Once the form is filled out, it should be mailed or faxed to Centralized Intake for Abuse & Neglect, or emailed to the provided DHS-CPS-CIGroup email address. Remember, filling out this form accurately and completely is crucial for the safety and well-being of the child or children involved.

Obtain Answers on Dhs 3200

  1. What is the purpose of the DHS 3200 form?

    The DHS 3200 form serves as an essential tool for communication with the Michigan Department of Human Services. Its primary function is to document and report instances of actual or suspected child abuse or neglect. By completing this form, individuals can provide detailed information necessary for the DHS to initiate an investigation and ensure the safety and well-being of involved child(ren).

  2. Who should complete the DHS 3200 form?

    The form is designed to be filled out by reporting persons, including but not limited to healthcare professionals, educators, social workers, and law enforcement officers, who have reasons to believe that a child is a victim of abuse or neglect. Sections 1-19 are specifically allotted for their input. Additionally, if a physical examination of the child has been conducted, medical personnel are required to complete items 20-28.

  3. Is it mandatory to phone in a report before completing the DHS 3200 form?

    Yes, it is mandatory. Before filling out the form, the individual suspecting child abuse or neglect must contact Centralized Intake by calling 855-444-3911. If the report was previously phoned in, the caller should indicate the provided Log # on the form. This step ensures immediate attention to the potentially critical situation.

  4. Can additional sheets be attached if there is more information to provide?

    Yes, individuals are encouraged to attach additional sheets if the space provided on the DHS 3200 form is insufficient. This allows for a comprehensive report, ensuring that all relevant details concerning the suspected abuse or neglect are thoroughly communicated to child protective services.

  5. What should be done if the child has a disability?

    When reporting suspected abuse or neglect involving a child with a disability, it is crucial to indicate the need for accommodation. This information helps ensure that all subsequent actions taken by DHS are appropriate and sensitive to the child’s specific needs.

  6. Where should the completed DHS 3200 form be sent?

    Once fully completed, the form should be mailed to Centralized Intake for Abuse & Neglect at the address provided on the form. Alternatively, it can be faxed or emailed to the numbers and address also listed, ensuring a timely submission.

  7. What happens after the DHS 3200 form is submitted?

    After submission, the information provided on the DHS 3200 form is reviewed by the Department of Human Services. If the report meets the criteria for suspected abuse or neglect, it triggers an official investigation. During this process, the DHS may contact the reporting individual for further information. The primary goal is to assess the situation accurately and take necessary actions to protect the child(ren) involved.

Common mistakes

When filling out the DHS 3200 form for reporting actual or suspected child abuse or neglect in Michigan, people often make mistakes that could impact the accuracy and efficacy of the report. Recognizing and avoiding these common errors can significantly aid in ensuring the report is correctly processed.

  1. Not providing detailed information on the child(ren) suspected of being abused or neglected. This includes failing to attach additional sheets when listing multiple children which is crucial for a comprehensive understanding of the situation.

  2. Omitting the relationship of the alleged perpetrator to the child(ren). This detail is critical because it helps the Michigan Department of Human Services understand the nature of the suspect’s interaction with the child(ren), which can be vital for the investigation.

  3. Forgetting to indicate if the complaint was previously phoned into DHS. Including the log number, if known, is important for cross-reference and tracking purposes, ensuring that the report is swiftly associated with any prior reports or calls regarding the same incident or individuals.

  4. Leaving out the details of any disabilities of the child(ren), mother, father, or other involved individuals which may require accommodation. This oversight can hinder the provision of appropriate support and services to those involved.

Additionally, here are supplementary recommendations for avoiding mistakes:

  • Review the form thoroughly before submission: Ensure all applicable sections are completed fully.
  • Attach additional documentation if necessary: Medical reports or any other relevant documentation should be attached to provide a complete picture of the situation.
  • Use clear and descriptive language: When describing the injury, conditions, or reasons for suspicion, clear descriptions help DHS workers understand the situation accurately.
  • Double-check addresses and contact information: Incorrect or incomplete information can delay the response or the investigation process.

By paying attention to these details, individuals can assist the Michigan Department of Human Services more effectively in responding to potential child abuse and neglect cases.

Documents used along the form

When handling child abuse or neglect cases, prompt and thorough documentation is vital not only for the protection of the child but also to ensure that all involved parties are accountable. The DHS 3200 form, a critical component in reporting suspected child abuse or neglect in Michigan, is typically not the only document involved in such cases. Various other forms and documents often accompany this form, each serving an essential purpose in the reporting and investigation process.

  • Child Welfare Information Gateway Request Form - This form is used to request information or resources related to child welfare, including statistics, research, or training materials that could provide additional context or support for a case.
  • Medical Examination Form for Child Abuse/Neglect - A detailed form completed by healthcare professionals after examining a child who is suspected of being abused or neglected, documenting physical and any relevant psychological findings.
  • Consent to Release Information Form - This document is necessary for obtaining permission to release or exchange confidential information about the child or family with other professionals involved in the case.
  • Family Assessment Form - Used by social workers to assess the family's situation and needs, this comprehensive form helps in developing an appropriate plan of action to support and protect the child.
  • Child Behavior Checklist - A tool for assessing behavioral and emotional problems in children, completed by parents, teachers, or caregivers, it's instrumental in understanding the child's well-being and identifying any psychological effects of abuse or neglect.
  • Safety Plan Agreement - An important document outlining the steps a parent or guardian agrees to take to ensure the child's safety. It's a critical part of the intervention process in cases of suspected abuse or neglect.
  • Police Report - If law enforcement is involved, a copy of the police report may be included, detailing the officers' observations and actions taken at the scene.
  • Court Orders - In cases where legal action is necessary, copies of any court orders related to the protection of the child, restraining orders against the alleged abuser, or custody arrangements may be included.

Each document plays a unique role in the child protection process, offering a more comprehensive view of the child's situation and helping ensure that all aspects of their welfare are considered. Professionals working in child welfare must be familiar with these forms and documents, understanding not only how to complete them but also how they work together to protect vulnerable children.

Similar forms

  • The SSA-561 Form is similar because it involves providing detailed personal information and specific circumstances, in this case, for appealing Social Security decisions. Like the DHS 3200 form, it contains sections for the reporting party to fill out, including contact information and specifics about the case at hand.

  • The VA 10-10EZ Form for enrollment in the VA health care system also shares similarities. It collects comprehensive personal, financial, and health information from the applicant. Both forms are structured to gather all necessary data in a streamlined manner to process the applicant's request.

  • The I-130 Petition for Alien Relative by the U.S. Citizenship and Immigration Services necessitates detailed documentation of the petitioner's and the beneficiary's personal information. Much like the DHS 3200, it's designed to document specific relationships and circumstances thoroughly for official review.

  • WIC Program Application Forms at the state level also resemble the DHS 3200 form as they require comprehensive details about the applicant, including household size, income, and nutritional risk factors. Both sets of forms focus on the well-being of children and vulnerable populations, collecting data aimed at providing necessary support services.

Dos and Don'ts

When filling out the DHS 3200 form, a report of actual or suspected child abuse or neglect for the Michigan Department of Human Services, there are specific dos and don'ts one should follow to ensure the form is completed correctly and efficiently.

Do:
  • Read the instructions carefully before you start filling in the form. The instructions provide crucial information on how to accurately report the necessary details.
  • Provide detailed information about the child or children suspected of being abused or neglected, including names, birth dates, and addresses, to help authorities respond effectively.
  • Indicate if the report was phoned into DHS beforehand, including the log number if available. This ensures the report is correctly linked with any previous notifications.
  • Contact Centralized Intake immediately if the report has not been phoned to DHS, using the provided contact information (855-444-3911) to ensure that the case is promptly addressed.
Don't:
  • Leave sections incomplete. If a section is not applicable, indicate with "N/A" or "Not Applicable" to show that the question was not overlooked.
  • Forget to attach additional sheets if more space is needed, particularly when listing the child(ren) suspected of being abused or neglected. Clearly indicate these attachments belong to the DHS 3200 form submission.
  • Submit without reviewing the information for accuracy. This helps prevent delays in the response due to incorrect or missing details.
  • Overlook the signature section. While only medical personnel are required to sign parts of the form, ensuring that all filled sections are accurate and accountable is crucial for all reporters.

Misconceptions

When it comes to understanding the DHS 3200 form, required for reporting actual or suspected child abuse or neglect in Michigan, there are a number of common misconceptions. It's crucial to address these misunderstandings to ensure that individuals and professionals are properly equipped to take action in safeguarding children. Here are five common misconceptions and the clarifications:

  • Misconception #1: The form is only for use by healthcare professionals. In reality, the DHS 3200 form is designed for use by a wide range of individuals including, but not limited to, teachers, social workers, law enforcement officers, and members of the clergy. This broad category ensures that anyone who suspects child abuse or neglect, and is in a position to observe signs of such, can report it.

  • Misconception #2: You need conclusive evidence of abuse or neglect to complete the form. The truth is, completing and submitting the DHS 3200 form does not require you to have conclusive evidence. The form is a tool for reporting both actual and suspected cases based on reasonable grounds. This means that if you have a suspicion, it's important to report it so that professionals can investigate further.

  • Misconception #3: All sections of the form must be completed for it to be valid. Though it's important to provide as much information as possible, not every section will be applicable to every situation. The key is to complete the form as comprehensively as your knowledge of the situation allows. Items 20-28, for example, are specifically for medical personnel to complete if a physical examination has been done.

  • Misconception #4: Reporting suspected abuse or neglect will automatically result in children being removed from their homes. Many people hesitate to fill out the form for fear of contributing to the separation of families. However, the primary aim of the Department of Human Services (DHS) is to ensure the child's safety and welfare. Removal from the home is considered a last resort, and not all reports lead to this outcome. The process involves thorough investigation and efforts to address the issues while keeping families intact whenever possible.

  • Misconception #5: Once submitted, the DHS 3200 form will lead to immediate action. While the DHS prioritizes the safety of children and acts as swiftly as possible, the process requires gathering of information, assessments, and sometimes coordination with other agencies. Therefore, immediate action, though ideal, is not always feasible due to the complexities involved in verifying reports and determining the best course of action.

Understanding these aspects of the DHS 3200 form encourages a more informed and proactive approach to reporting child abuse and neglect. It's a vital part of community responsibility, ensuring that vulnerable children receive the protection and care they need.

Key takeaways

Understanding how to accurately fill out the DHS 3200 form is crucial for responsible reporting of actual or suspected child abuse or neglect in Michigan. Here are six key takeaways to ensure the process is both effective and compliant with state requirements:

  1. Immediately Contact Centralized Intake if the Complaint Was Not Already Phoned In: It's essential that any suspicion of child abuse or neglect is reported as soon as possible. If the complaint has not yet been phoned in to DHS, contact Centralized Intake (855-444-3911) without delay.
  2. Complete All Relevant Sections Thoroughly: Sections 1-19 of the DHS 3200 form are to be filled out by the reporting person. This includes detailed information about the child or children suspected of being abused or neglected, the nature of the suspected abuse or neglect, and information about the alleged perpetrator.
  3. Attach Additional Sheets if Necessary: If there's more information than what can fit in the provided spaces—such as listing multiple children or providing a comprehensive description of the suspected abuse or neglect—additional sheets should be attached.
  4. Medical Personnel Sections: Only medical personnel are to complete sections 20-28, which are related to the physical examination of the child or children in question, including summaries, conclusions, and any relevant medical documentation.
  5. Use the Correct Method to Submit the Form: The completed form can be mailed, faxed, or emailed to Centralized Intake for Abuse & Neglect. The specific addresses and fax numbers are provided on the form, ensuring multiple channels are available for submission.
  6. Support is Available for Those Who Need It: The Department of Human Services (DHS) emphasizes non-discrimination and the availability of assistance under the Americans with Disabilities Act (ADA). Anyone needing help due to a disability can make their needs known to a DHS office in their area.

Timeliness and accuracy in completing and submitting the DHS 3200 form are key to ensuring that suspected cases of child abuse or neglect are investigated and addressed promptly. By following these takeaways, individuals can contribute to the protection of children in Michigan effectively.

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