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Addressing the critical responsibility of safeguarding children, the DHS 3200 form serves as a vital tool in the reporting of actual or suspected child abuse or neglect. Issued by the Michigan Department of Human Services, this form ensures that allegations receive the necessary attention and intervention to protect children in potentially harm's way. The form encompasses a meticulous process, starting with whether the initial complaint was made by phone to ensure immediate action. It then guides the reporter through detailed sections, each designed to gather comprehensive information about the child or children in question, including personal details, living circumstances, and the specifics of the alleged abuse or neglect. Importantly, it calls for the identification of the alleged perpetrator, emphasizing the necessity of understanding the relationship dynamics that may contribute to such situations. Medical personnel have a designated section for inputs related to physical examinations, further underscoring the form's thorough approach in documenting evidence of abuse or neglect. The requirement for this form follows legislative mandates under the protection act, highlighting its legal importance in child welfare processes. The form not only facilitates a structured reporting mechanism but also reflects the broader commitment of the Michigan Department of Human Services to actively combat child abuse and neglect, ensuring that every report is given proper attention while fostering a system that accommodates individuals regardless of their background.

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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
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Document Attributes

Fact Description
Form Purpose This form serves as a written follow-up to an oral report of actual or suspected child abuse or neglect in Michigan.
Required by Law The completion of this form is mandated under the authority of P.A. 238 of 1975.
Key Sections for Reporting Person Items 1-19 are to be completed by the person reporting the abuse or neglect, providing details such as the date, names, and addresses involved, including the suspected perpetrator.
Medical Personnel Section Items 20-28 are specifically reserved for completion by medical personnel, detailing any physical examinations, laboratory reports, and medical conclusions.
Non-Discrimination Statement The Department of Human Services commits to non-discrimination based on race, religion, age, and other listed categories in its service provision.
Submission Details After completion, the form can be mailed, faxed, or emailed to the Centralized Intake for Abuse & Neglect, with multiple contact methods provided.

How to Fill Out Dhs 3200

After recognizing a situation that may involve the abuse or neglect of a child, individuals are obligated to report their concerns to the appropriate authorities. The DHS 3200 form serves as a formal documentation of these concerns and is a critical step in ensuring the safety and well-being of vulnerable children. Filling out this form requires accuracy and diligence to provide a comprehensive account of the suspect circumstances that prompted the report. This documentation will be reviewed by specialized personnel who will determine the necessary steps to address the reported concerns. Here's how to complete the form:

  1. Write the date you are filling out the form in the space provided.
  2. Under item 2, list the child or children suspected of being abused or neglected, including their names, birth dates, social security numbers, sex, and race. Attach additional sheets if needed.
  3. Enter the mother's name and any other pertinent details such as potential accommodations for disabilities under item 3.
  4. For item 4, provide the father's name and any additional relevant information similar to what was provided for the mother.
  5. Fill in the child or children's address, including number and street, under items 5-7, city in item 6, and county in item 7.
  6. Input the phone number of the household where the child or children reside(s) in item 8.
  7. Record the name of the alleged perpetrator of abuse or neglect in item 9, along with their relationship to the child or children in item 10.
  8. Specify who the child or children were living with when the abuse or neglect occurred in item 11.
  9. Document the address where the abuse or neglect occurred in item 12.
  10. Describe the injury, condition, and reasons for suspicion of abuse or neglect in item 13.
  11. Check the source of complaint in item 14, noting the professional group or category that applies.
  12. For items 15-19, enter the reporting person's name, address, phone number, and organization if applicable. Use the report code provided in the form to denote your relationship to the case.

Upon form completion, send it to the address or fax noted in the instructions, or email it to the provided address, ensuring that this critical information reaches the Centralized Intake for Abuse & Neglect. This action could be pivotal in safeguarding the welfare of a child and initiating the necessary support and interventions.

More About Dhs 3200

  1. What is the DHS-3200 form and who is required to complete it?

    The DHS-3200 form is an official document used to report cases of actual or suspected child abuse or neglect in the state of Michigan. It serves as a written follow-up to any oral reports previously made to the Department of Human Services (DHS) about such concerns. This form is typically filled out by professionals who come into contact with children through their work, including but not limited to medical personnel, educators, social workers, and law enforcement officers. The form must be filled out as completely as possible by the reporting person, with sections 20-28 specifically reserved for completion by medical personnel if a physical examination has been conducted.

  2. What should you do if you haven't phoned in your report to DHS before filling out the DHS-3200 form?

    If you have not previously phoned in your report to the Centralized Intake at DHS before attempting to fill out the DHS-3200 form, it is crucial to contact them immediately at 855-444-3911. The oral report is a required first step in the process of reporting suspected child abuse or neglect. After making this initial report, you will be provided with a Log Number which you will need to include on the DHS-3200 form.

  3. How should you submit the completed DHS-3200 form?

    Once the DHS-3200 form has been filled out, it can be submitted to the Centralized Intake for Abuse & Neglect in several ways: it can be mailed to the provided address in Grand Rapids, MI, sent via fax to one of the four listed numbers, or emailed to the specified DHS email. This flexibility ensures that the form can be submitted in the manner most convenient or accessible to the reporting person.

  4. What information is required on the DHS-3200 form?

    • Date the form is being completed.
    • Information on the child(ren) suspected of being abused or neglected, including name, birth date, social security number, sex, and race, among other details.
    • Details about the child(ren)’s living situation and the person(s) they were living with when the abuse or neglect occurred.
    • Identification of the alleged perpetrator of abuse or neglect and their relationship to the child(ren).
    • A description of the injury or conditions that led to the suspicion of abuse or neglect, including any evidence or reasons for the suspicion.

    This information helps DHS to assess the situation accurately and take appropriate action to protect the child(ren) involved.

  5. Is completion of the DHS-3200 form mandatory, and are there any penalties for not completing it?

    Yes, completion of the DHS-3200 form is mandatory under the authority of P.A. 238 of 1975. However, the form itself states that there is no penalty for not completing it. It's important to note, though, that professionals mandated by law to report suspected child abuse or neglect could face legal consequences if they fail to make a report. The DHS-3200 form is part of the reporting process, designed to ensure that suspected cases are properly documented and investigated.

Common mistakes

  1. Not indicating whether the complaint was initially reported by phone to DHS. This critical step ensures the report is processed promptly.

  2. Failing to list all suspected child(ren) and relevant details such as name, birth date, and social security number. Completeness in this section is vital for a thorough investigation.

  3. Leaving the section about the child(ren)'s address and contact information incomplete. Accurate information here is crucial for direct follow-up and ensuring the child(ren)'s safety.

  4. Omitting details about the alleged perpetrator of abuse or neglect, including their name and relationship to the child. Identifying the alleged perpetrator is essential for the investigation process.

  5. Not specifying the address where the abuse or neglect occurred, if different from the child’s address. This information is crucial for understanding the context and environment of the alleged incident.

  6. Skipping the description of injury or conditions that led to the suspicion of abuse or neglect. Detailed observations support the need for a closer examination and intervention.

Common mistakes also include:

  • Not attaching additional sheets when more space is needed to list multiple children or provide detailed descriptions. This oversight can lead to incomplete information being reported.

  • Incorrectly identifying the source of the complaint by not checking the appropriate box or providing the report code. Accurate identification helps categorize the urgency and type of response needed.

  • Leaving the reporter’s contact information blank, which can impede follow-up questions or clarification. The reporter's contact details are key for any additional inquiries or clarification.

Documents used along the form

When dealing with a case of actual or suspected child abuse or neglect, the DHS-3200 form plays a crucial role in Michigan's protocol for reporting these serious matters. However, to comprehensively assess and address such concerns, additional forms and documents are often utilized in conjunction with the DHS-3200. These supplementary documents are vital for providing a fuller picture of the situation, ensuring appropriate measures are taken to protect the child or children involved.

  • Medical Examination Report: This document contains detailed findings from a physical examination conducted by a healthcare professional. It offers crucial evidence about the child's physical state and can corroborate details reported on the DHS-3200 form regarding injuries or signs of neglect.
  • Police Report: If law enforcement was involved at any point, the police report would provide an objective account of the circumstances as observed or investigated by officers. This can include witness statements, the result of any initial investigation, and documentation of any immediate actions taken to protect the child.
  • Child's Statement: A documented account of the child’s own words regarding their experiences can provide invaluable insight. This is often recorded during interviews with social workers, psychologists, or child advocacy specialists trained to talk with children about sensitive subjects.
  • School Reports: Educators and school personnel can offer unique perspectives on a child's welfare through reports on attendance, behavior, and academic performance. These insights can be critical, especially in cases where neglect is suspected, highlighting changes in the child's demeanor or performance over time.
  • Witness Statements: Written accounts from neighbors, family members, or others who have observations relevant to the case can supplement the information provided in the DHS-3200 form. These statements can clarify the child's living conditions, the behavior of the suspected abuser, and any visible signs of abuse or neglect.

Comprehensive assessment and intervention in child abuse and neglect cases require a multi-faceted approach, utilizing various documents alongside the DHS-3200 form. These documents provide essential context and evidence that support protective actions and help ensure the child's safety and well-being. Professionals across disciplines collaborate, using these tools to build a thorough case that addresses both the immediate and long-term needs of the child.

Similar forms

  • The Intake Form for Domestic Violence Victims is akin to the DHS 3200 form. Similar to the DHS 3200, it collects sensitive and critical information, including personal details, to ensure the safety and support of individuals at risk, mirroring the urgency and confidentiality with which child abuse and neglect reports are handled.

  • The Medical Examination Report for Employment shares commonalities with the DHS 3200 form, especially in sections 20-28 where medical personnel complete details about physical examinations. Both forms play a crucial role in capturing health-related information that could affect the subject's well-being or job performance, respectively.

  • The Elder Abuse and Neglect Reporting Form has similarities with the DHS 3200 form by serving a protective function for a vulnerable segment of the population. Both documents are structured to collect detailed information regarding the alleged abuse, including perpetrator details and circumstances surrounding the incident.

  • The Special Education Needs Assessment Form is comparable to the DHS 3200 form in that it gathers detailed information about a child's specific condition, needs, and the environment, focusing on tailoring interventions or services to the individual. It prioritizes understanding and addressing individual vulnerabilities, similar to how DHS 3200 aims to safeguard children.

  • The Substance Abuse Assessment Form parallels the DHS 3200 form in its detailed inquiry into an individual's situation, including personal history and environmental factors contributing to the condition. Both forms initiate a process aimed at providing necessary interventions for the welfare of the individual or child.

  • The Patient Intake Form in Healthcare Settings resembles the sections of the DHS 3200 form where medical information is crucial, particularly for sections asking for a summary report and conclusions of physical examinations. Both are essential in initiating care and support based on the individual's health status and needs.

  • The Police Report Form for Assault Cases is related to the DHS 3200 form since both document specific incidents of harm or potential harm, necessitating immediate and appropriate responses. They each record detailed accounts of the event, including information about the victim, perpetrators, and the circumstances of the incident.

Dos and Don'ts

When completing the DHS 3200 form for the Report of Actual or Suspected Child Abuse or Neglect in Michigan, it is crucial to approach the task with both precision and understanding. This form plays a significant role in initiating the investigative process by the Michigan Department of Human Services, hence the need for clarity and detail. Below is a list of things one should and shouldn't do when filling out this form:

  • Do make the phone call first if you haven't already. If the suspected abuse or neglect hasn’t been reported by phone, do so immediately by contacting Centralized Intake.
  • Do fill out the form as completely and accurately as possible. Include detailed information on the child or children suspected of being abused or neglected, ensuring to capture all relevant data required in items 1-19.
  • Do include any known disabilities of the child or parent(s) that may require accommodation. Such information ensures that any investigation or subsequent action taken is done with sensitivity to special needs.
  • Do provide a clear and concise description of the injuries or conditions that led to the suspicion of abuse or neglect, including any pertinent details that could support the investigation.
  • Don't leave sections blank. If certain information is unavailable or unknown, specify this rather than omitting information, as this helps to convey the thoroughness of your report.
  • Don't forget to indicate your relationship to the child or children reported, if applicable, or specify the capacity in which you're reporting (e.g., as a teacher or healthcare provider).
  • Don't assume information is irrelevant. If in doubt about including specific details, err on the side of providing the information; it could be more important to the case than you realize.
  • Don't submit the form without reviewing it for completeness and accuracy. Mistakes or omissions can delay the processing and investigation of the report. Ensure all relevant sections, especially those pertaining to the alleged perpetrator and the circumstances of the suspected abuse or neglect, are filled out thoroughly.

Adherence to these guidelines will facilitate a more efficient and effective response to suspected child abuse or neglect reports. Remember, the primary goal is to ensure the safety and well-being of the child or children involved. Your careful attention to detail in completing the DHS 3200 form can significantly aid in achieving this outcome.

Misconceptions

Understanding the DHS 3200 form, used for reporting actual or suspected child abuse or neglect in Michigan, is crucial. However, there are several common misconceptions about the process. Here we'll clarify these misunderstandings to ensure the protection and welfare of children is effectively addressed.

  • A common misconception is that anyone can report abuse or neglect anonymously using the DHS 3200 form. While the form does cater to anonymous reporting, it strongly encourages reporters to provide their names to facilitate follow-up and comprehensive investigation.

  • Another misunderstanding is that only professionals working with children can file this report. In fact, anyone, including neighbors, relatives, or concerned citizens, can and is encouraged to report if they suspect child abuse or neglect. The form includes a wide array of reporter codes, reflecting that various individuals, including medical personnel and school counselors, can report, but it is not limited to them exclusively.

  • Some people believe that submission of the DHS 3200 form is optional after contacting DHS by phone. This belief is incorrect; following an oral report, the completion and submission of the form is a mandatory step to provide a detailed, written follow-up of the suspicions reported.

  • There's also a misconception that the form is only for reporting physical abuse. The DHS 3200 form is designed to report both actual or suspected child abuse or neglect, encompassing a range of issues beyond physical harm, including neglect and emotional abuse.

  • Finally, a significant misunderstanding revolves around the immediate actions taken post-report. Some believe that once a report is filed, immediate action to remove the child from the home is taken. However, the primary goal is to ensure the child's safety, which might involve various steps, including investigation, family support initiatives, or other interventions tailored to the child's and family's needs.

By dispelling these misconceptions, individuals can better understand their role and the procedures involved in safeguarding children against abuse and neglect. It is everyone's responsibility to protect the welfare of children, and having accurate information about the reporting process is a vital component of this duty.

Key takeaways

When dealing with the DHS 3200 form, which is essential for reporting actual or suspected child abuse or neglect in Michigan, it's important to understand its key features and requirements. This form serves as a vital tool for initiating the investigation process and ensuring the safety of children. Here are five key takeaways to consider:

  • Immediate reporting is crucial: If the initial report of suspected abuse or neglect was not made by phone to the Department of Human Services (DHS), it should be done immediately by contacting Centralized Intake. This ensures that the appropriate actions are taken without delay to protect the child or children involved.
  • Detailed information is key: Filling out the form with as much detail as possible is essential. This includes comprehensive information about the child or children suspected of being abused or neglected, such as names, birth dates, social security numbers, and addresses, along with information about the alleged perpetrator and the circumstances surrounding the suspected abuse or neglect.
  • Specific sections for medical personnel: The DHS 3200 form has sections designated specifically for completion by medical personnel (items 20-28). These sections are crucial for documenting physical examinations, laboratory reports, X-rays, and any other medical evidence of abuse or neglect, providing a clearer picture of the child's condition and aiding in the investigation.
  • Non-discrimination policy: The form includes a statement emphasizing the Michigan Department of Human Services' commitment to non-discrimination. This assurance covers race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs, or disability, ensuring that all reports are handled with fairness and respect for everyone involved.
  • Multiple submission options: The form allows for various submission methods, including mail, fax, or email to the Centralized Intake for Abuse & Neglect. This flexibility ensures that individuals can choose the most convenient or fastest way to submit their report, facilitating a more efficient process in providing the necessary intervention for the child or children in question.

Ultimately, the DHS 3200 form is a critical component of Michigan's child protective services system, designed to streamline the reporting process and ensure that suspected cases of child abuse or neglect are investigated promptly and thoroughly. By providing clear, complete, and accurate information when filling out this form, individuals can play a key role in protecting children and supporting their well-being.

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