Form DCF-136 "Report of Suspected Child Abuse or Neglect" - Connecticut

What Is Form DCF-136?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-136 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-136 "Report of Suspected Child Abuse or Neglect" - Connecticut

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REPORT OF SUSPECTED CHILD ABUSE OR NEGLECT
DCF-136
Careline
05/2015 (Rev.)
1-800-842-2288
Within forty-eight hours of making an oral report, a mandated reporter shall submit this form (DCF-136) to the relevant Area Office listed below
See the reverse side of this form for a summary of Connecticut law concerning the protection of children.
Please Print or Type
Child’s Name
Age Or DOB
Race:
American Indian or Alaskan Native
Hispanic
M
Asian/Pacific Islander
White (not of Hispanic origin)
F
Black/African American (not of
Unknown
Hispanic Origin)
Other ____________________
Child’s Address
Name Of Parents Or Other Person Responsible For Child’s Care
Address
Phone Number
Name Of Careline Worker To Whom Oral Report Was Made
Date Of Oral Report
Date And Time Of Suspected Abuse/Neglect
Name Of Suspected Perpetrator, If Known
Address And Phone Number, If Known
Relationship To Child
Nature And Extent Of Injury(ies), Maltreatment Or Neglect
Describe The Circumstances Under Which The Injury(ies), Maltreatment Or Neglect Came To Be Known
Describe the Reasons Such Persons(s) Are Suspected of Causing Such Injuries, Maltreatment of Neglect
Information Concerning Any Previous Injury(ies), Maltreatment Or Neglect Of The Child Or His/Her Siblings
Information Concerning Any Prior Cases(s) In Which The Person(s) Have Been Suspected Of Causing An Injury(ies), Maltreatment Or Neglect Of A Child
List Names And Ages Of Siblings, If Known
What Action, If Any, Has Been Taken To Treat, Provide Shelter Or Otherwise Assist The Child?
REPORTER SECTION
Reporter’s Name:
Reporter’s Race
American Indian or Alaskan Native
Agency Name:
Asian/Pacific Islander
Black/African American (not of Hispanic Origin)
Phone Number:
Hispanic (any race)
Agency Address:
White (not of Hispanic origin)
Prefer Not to Answer
City:
Other ______________________________________
Reporter’s Signature
Position
Date
WHITE COPY: TO DCF AREA OFFICE (see below)
IF YOU NEED ADDITIONAL SPACE, YOU MAY ATTACH MORE DOCUMENTATION
Bridgeport
Danbury
Hartford
Manchester
Norwalk
100 Fairfield Avenue
131 West Street
250 Hamilton Street
364 West Middle Turnpike
761 Main Avenue, I-Park Complex
Bridgeport, CT 06604
Danbury, CT 06810
Hartford, CT 06106
Manchester, CT 06040
Norwalk, CT 06851
203-384-5300
203-207-5100
860-418-8000
860-533-3600
203-899-1400
TDD: 203-384-5399
TDD: 203-748-8325
TDD: 800-315-4082
TDD: 800-315-4415
TDD: 203-899-1491
Fax: 203-384-5306
Fax: 203-207-5169
Fax: 860-418-8325
Fax: 860-533-3734
Fax: 203-899-1463, 203-899-1464
Meriden
Middletown
Milford
New Britain
New Haven
One West Main Street
2081 South Main Street
38 Wellington Road
One Grove Street, 4th Floor
One Long Wharf Drive
Meriden CT 06451
Middletown, CT 06457
Milford, CT 06461
New Britain, CT 06053
New Haven, CT 06511
203-238-8400
860-638-2100
203-306-5300
860-832-5200
203-786-0500
TDD: 203-238-8517
TDD: 860-638-2195
TDD: 203-306-5604
TDD: 860-832-5370
TDD: 203-786-2599
Fax: 203-238-6425
Fax: 860-346-0098
Fax: 203-306-5606
Fax: 860-832-5491
Fax: 203-786-0660
Norwich
Torrington
Waterbury
Willimantic
Special Investigations Unit
th
Two Courthouse Square
62 Commercial Blvd
395 West Main Street
322 Main Street
505 Hudson Street, 7
Floor
Norwich, CT 06360
Torrington, CT 06790
Waterbury, CT 06702
Willimantic, CT 06226
Hartford, CT 06106
860-886-2641
860-496-5700
203-759-7000
860-450-2000
860-550-6696
TDD: 860-885-2438
TDD: 860-496-5798
TDD: 203-465-7329
TDD: 860-456-6603
FAX: 860-723-7237
Fax: 860-887- 3683
Fax: 860-496-5834
Fax: 203-759-7295
Fax: 860-450-1051
REPORT OF SUSPECTED CHILD ABUSE OR NEGLECT
DCF-136
Careline
05/2015 (Rev.)
1-800-842-2288
Within forty-eight hours of making an oral report, a mandated reporter shall submit this form (DCF-136) to the relevant Area Office listed below
See the reverse side of this form for a summary of Connecticut law concerning the protection of children.
Please Print or Type
Child’s Name
Age Or DOB
Race:
American Indian or Alaskan Native
Hispanic
M
Asian/Pacific Islander
White (not of Hispanic origin)
F
Black/African American (not of
Unknown
Hispanic Origin)
Other ____________________
Child’s Address
Name Of Parents Or Other Person Responsible For Child’s Care
Address
Phone Number
Name Of Careline Worker To Whom Oral Report Was Made
Date Of Oral Report
Date And Time Of Suspected Abuse/Neglect
Name Of Suspected Perpetrator, If Known
Address And Phone Number, If Known
Relationship To Child
Nature And Extent Of Injury(ies), Maltreatment Or Neglect
Describe The Circumstances Under Which The Injury(ies), Maltreatment Or Neglect Came To Be Known
Describe the Reasons Such Persons(s) Are Suspected of Causing Such Injuries, Maltreatment of Neglect
Information Concerning Any Previous Injury(ies), Maltreatment Or Neglect Of The Child Or His/Her Siblings
Information Concerning Any Prior Cases(s) In Which The Person(s) Have Been Suspected Of Causing An Injury(ies), Maltreatment Or Neglect Of A Child
List Names And Ages Of Siblings, If Known
What Action, If Any, Has Been Taken To Treat, Provide Shelter Or Otherwise Assist The Child?
REPORTER SECTION
Reporter’s Name:
Reporter’s Race
American Indian or Alaskan Native
Agency Name:
Asian/Pacific Islander
Black/African American (not of Hispanic Origin)
Phone Number:
Hispanic (any race)
Agency Address:
White (not of Hispanic origin)
Prefer Not to Answer
City:
Other ______________________________________
Reporter’s Signature
Position
Date
WHITE COPY: TO DCF AREA OFFICE (see below)
IF YOU NEED ADDITIONAL SPACE, YOU MAY ATTACH MORE DOCUMENTATION
Bridgeport
Danbury
Hartford
Manchester
Norwalk
100 Fairfield Avenue
131 West Street
250 Hamilton Street
364 West Middle Turnpike
761 Main Avenue, I-Park Complex
Bridgeport, CT 06604
Danbury, CT 06810
Hartford, CT 06106
Manchester, CT 06040
Norwalk, CT 06851
203-384-5300
203-207-5100
860-418-8000
860-533-3600
203-899-1400
TDD: 203-384-5399
TDD: 203-748-8325
TDD: 800-315-4082
TDD: 800-315-4415
TDD: 203-899-1491
Fax: 203-384-5306
Fax: 203-207-5169
Fax: 860-418-8325
Fax: 860-533-3734
Fax: 203-899-1463, 203-899-1464
Meriden
Middletown
Milford
New Britain
New Haven
One West Main Street
2081 South Main Street
38 Wellington Road
One Grove Street, 4th Floor
One Long Wharf Drive
Meriden CT 06451
Middletown, CT 06457
Milford, CT 06461
New Britain, CT 06053
New Haven, CT 06511
203-238-8400
860-638-2100
203-306-5300
860-832-5200
203-786-0500
TDD: 203-238-8517
TDD: 860-638-2195
TDD: 203-306-5604
TDD: 860-832-5370
TDD: 203-786-2599
Fax: 203-238-6425
Fax: 860-346-0098
Fax: 203-306-5606
Fax: 860-832-5491
Fax: 203-786-0660
Norwich
Torrington
Waterbury
Willimantic
Special Investigations Unit
th
Two Courthouse Square
62 Commercial Blvd
395 West Main Street
322 Main Street
505 Hudson Street, 7
Floor
Norwich, CT 06360
Torrington, CT 06790
Waterbury, CT 06702
Willimantic, CT 06226
Hartford, CT 06106
860-886-2641
860-496-5700
203-759-7000
860-450-2000
860-550-6696
TDD: 860-885-2438
TDD: 860-496-5798
TDD: 203-465-7329
TDD: 860-456-6603
FAX: 860-723-7237
Fax: 860-887- 3683
Fax: 860-496-5834
Fax: 203-759-7295
Fax: 860-450-1051
SUMMARY OF LEGAL REQUIREMENTS CONCERNING CHILD ABUSE/ NEGLECT
DEFINITIONS OF ABUSE AND NEGLECT
PUBLIC POLICY OF THE STATE OF CONNECTICUT (C.G.S. §17a-101)
Abused Child: Any child who has a non-accidental physical injury, or injuries which are at
variance with the history given of such injuries, or is in a condition which is the result of
To protect children whose health and welfare may be adversely affected
maltreatment such as, but not limited to, malnutrition, sexual molestation, deprivation of
through injury and neglect; to strengthen the family and to make the home
necessities, emotional maltreatment or cruel punishment.
safe for children by enhancing the parental capacity for good child care; to
provide a temporary or permanent nurturing and safe environment for
Neglected Child: Any child who has been abandoned or is being denied proper care and
children when necessary; and for these purposes to require the reporting of
attention, physically, educationally, emotionally, or morally or is being permitted to live under
suspected child abuse or neglect, investigation of such reports by a social
conditions, circumstances or associations injurious to his or her well-being.
agency, and provision of services, where needed, to such child and family.
Exception: The treatment of any child by an accredited Christian Science practitioner shall
WHO IS MANDATED TO REPORT CHILD ABUSE/NEGLECT?
not by itself constitute neglect or maltreatment.
Child Advocate and OCA Employees
Mental Health Professionals
Chiropractors
Optometrists
CHILD UNDER AGE 13 WITH VENEREAL DISEASE: A physician or facility must report to
Coaches and Directors of a Private Youth Sports,
Persons Paid to Care for Children
Careline upon the consultation, examination or treatment for venereal disease of any child who
has not reached his or her 13
birthday.
Organization or Team
Persons who Provide Services to
th
Coaches and Athletic Directors of Youth Athletics
and have Regular Contact with
Dental Hygienists
Students
DO PRIVATE CITIZENS HAVE A RESPONSIBILITY FOR REPORTING?
Dentists
Pharmacists
Yes. Any person having reasonable cause to suspect or believe that any child under the age
Physical Therapists
of 18 is in danger of being abused or has been abused or neglected may cause a written or
Department of Children and Families Employees
oral report to be made to the Careline or a law enforcement agency. Any person making the
Domestic Violence Counselors
Physician Assistants
Office of Early Childhood Employees and Department
Podiatrists
report in good faith is immune from any liability, civil or criminal. However, the person is
of Public health Employees who are Responsible
Police Officers
subject to the penalty for making a false claim.
for Licensing Day Cares and Camps
Probation Officers (Juvenile or Adult)
WHAT IS THE AUTHORITY AND RESPONSIBILITY OF THE DEPARTMENT OF CHILDREN
Family Relations Counselors (Judicial Dept.)
Psychologists
Family Rel. Counselor Trainees (Judicial Dept.)
Public or Private Institution of Higher
AND FAMILIES (DCF)?
Family Services Supervisors (Judicial Dept.)
Education Administrators, Faculty,
All child protective services in Connecticut are the responsibility of the Department of Children
Licensed Foster Parents
Staff, Athletic Directors, Athletic
and Families.
Licensed Marital and Family Therapists
Coaches and Athletic Trainers
Upon the receipt of a report of child abuse or neglect, the Careline shall cause the report to be
Licensed or Unlicensed Interns at Any Hospital
Registered Nurses
Licensed or Unlicensed Resident Physicians
School Administrators
classified, evaluated immediately and forwarded to the appropriate Area Office for the
Licensed Physicians
School Coaches
commencement of an investigation or for the provision of services within timelines specified by
Licensed Practical Nurses
School Guidance Counselors
statute and policy.
Licensed Professional Counselors
School Paraprofessionals
If an investigation produces evidence of child abuse or neglect, DCF shall take such measures
Licensed Surgeons
School Superintendents
Licensed/Certified Alcohol and Drug Counselors
School Teachers
as it deems necessary to protect the child, and any other children similarly situated, including,
Sexual Assault Counselors
but not limited to, immediate notification to the appropriate law enforcement agency, and the
Licensed/Certified Emergency Medical Services Providers
Medical Examiners
Social Workers
removal of the child from his or her home with or without the parents’ consent consistent with
state law.
Members of the Clergy
Substitute Teachers
DO THOSE MANDATED TO REPORT INCUR LIABILITY?
If DCF has probable cause to believe that the child or any other child in the household is at
No. Any person, institution or agency which, in good faith, makes or does not make a report,
imminent risk of physical harm from the surroundings, and that immediate removal from such
shall be immune from any civil or criminal liability provided such person did not perpetrate or
surroundings is necessary to ensure the child’s safety, the Commissioner or designee shall
authorize any employee of DCF or any law enforcement officer to remove the child and any
cause such abuse or neglect.
other child similarly situated from such surroundings without the consent of the child’s parent
IS THERE A PENALTY FOR NOT REPORTING?
or guardian. The removal of a child shall not exceed 96 hours. If the child is not returned
Yes. Any person required to report who fails to do so may be prosecuted for a Class A
home within such 96-hour period, with or without protective services, DCF shall file a motion
misdemeanor and may be required to participate in an educational and training program. Any
for temporary custody with the Superior Court for Juvenile Matters.
person who intentionally and unreasonably interferes with or prevents a report may be
prosecuted for a Class D felony.
WHAT MEANS ARE AVAILABLE FOR REMOVING A CHILD FROM HIS OR HER HOME?
96-Hour hold by the Commissioner of DCF or designee (see above).
IS THERE A PENALTY FOR MAKING A FALSE REPORT?
Yes. Any person who knowingly makes a false report of child abuse or neglect may be fined
96-Hour hold by a physician – Any physician examining a child with respect to whom
not more than $2,000 or imprisoned for not more than one year or both. The identity of such
abuse or neglect is suspected shall have the right to keep such child in the custody of a
person shall be disclosed to the appropriate law enforcement agency and to the alleged
hospital for no longer than 96 hours in order to perform diagnostic tests and procedures
perpetrator of the abuse.
necessary to the detection of child abuse or neglect and to provide necessary medical
care with or without the consent of such child’s parents or guardian or other person
WHAT ARE THE REPORTING REQUIREMENTS?
responsible for the child’s care, provided the physician has made reasonable attempts to
An oral report shall be made by a mandated reporter by telephone or in person to the DCF
(1) advise such child’s parents or guardian or other person responsible for the child’s care
Careline or to a law enforcement agency as soon as practicable, but not later than 12
that the physician suspects the child has been abused or neglected, and (2) obtain
hours after the mandated reporter has reasonable cause to suspect or believe that a child
consent of such child’s parents or guardian or other person responsible for the child’s
has been abused or neglected or placed in imminent risk of serious harm. If a law
care. In addition, such physician may take or cause to be taken photographs of the area
enforcement agency receives an oral report, it shall immediately notify Careline. Oral
of trauma visible on a child who is the subject of such report without the consent of such
reports to the Careline shall be recorded.
child’s parent’s or guardian or other person responsible for the child’s care. All such
photographs or copies thereof shall be sent to the local police department and the
Department of Children and Families.
Within 48 hours of making an oral report, a mandated reporter shall submit a written report
to the DCF Careline on the DCF-136, "Report of Suspected Child Abuse or Neglect."
Bench order of temporary custody – Whenever any person is arrested and charged with
When a mandated reporter is a member of the staff of a public or private institution or
an offense under Section 53-20 or 53-21 or under Part V, VI, or VII of Chapter 952, as
facility that provides care for children or a public or private school, the reporter shall also
amended, the victim of which offense was a minor residing with the defendant, any judge
submit a copy of the written report to the person in charge of such institution, school or
of the Superior Court may, if it appears that the child’s condition or circumstances
surrounding the case so require, issue an order to the Commissioner of the Department of
facility or the person's designee.
Children and Families to assume immediate custody of such child and, if the
circumstances so require, any other children residing with the defendant and to proceed
thereon as in other cases.
WHAT IS THE CENTRAL REGISTRY OF PERPETRATORS OF ABUSE OR NEGLECT?
The Department of Children and Families maintains a registry of persons who have been
DCF CHILD ABUSE AND NEGLECT CARELINE: 1-800-842-2288
substantiated as responsible for child abuse or neglect and pose a risk to the health safety or
well-being of children. The Central Registry is available on a 24-hour daily basis to prevent or
discover child abuse of children.
STATUTORY REFERENCES: C.G.S.17a-28, §17a-101 et seq.; §46b-120
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