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Get IL CANTS 5 2000

CANTS 5 Rev. 10/00 State of Illinois Department of Children and Family Services WRITTEN CONFIRMATION OF SUSPECTED CHILD ABUSE/NEGLECT REPORT MANDATED REPORTERS DATE ABOUT Child s Name Child s Birth Date If you are reporting more than one child from the same family please list their names and birth date in the space provided on the reverse side of this form. Street Address City Zip Code Parent/Custodians Name Address if different than the child s address This is to confirm my oral report of made in accordance with the Abused and Neglected Child reporting Act 325 ILCS 5 et seq. Please answer the following questions. If you need more space use the back of this page. What injuries or signs of abuse/neglect are there How and approximately when did the abuse/neglect occur and how did you become aware of the abuse/neglect Had there been evidence of abuse/neglect before now If the answer to question 3 is yes please explain the nature of the abuse/neglect. Names and addresses of other persons who may be willing to provide information about this case. Your relationship to child ren Reporter Action Recommended or Taken Yes No PLEASE CHECK THE APPROPRIATE RESPONSE I saw the child ren I heard about the child ren From whom have have not told the child s family of my concern and of my report to the Department. I willing NOT willing to tell the child s family of my concern and of my report to the Department. I am believe do NOT believe the child is in immediate physical danger. Name Printed Signature Title Organization/Agency INSTRUCTIONS ON REVERSE SIDE The Abused and Neglected Child Reporting Act states that mandated reporters shall promptly report or cause reports to be made in accordance with the provisions of the ACT. The report should be made immediately by telephone to the IDCFS Child Abuse Hotline 800-252-2873 and confirmed in writing via the U*S* Mail postage prepaid within 48 hours of the initial report. MAILING INSTRUCTIONS Mail the original to the nearest office of the Illinois Department of Children and Family Services Attention Child Protective Services. 2nd Child s Name If Any 2nd Child s Birth Date DCFS is an equal opportunity employer and prohibits unlawful discrimination in all of its programs and/or services. Please answer the following questions. If you need more space use the back of this page. What injuries or signs of abuse/neglect are there How and approximately when did the abuse/neglect occur and how did you become aware of the abuse/neglect Had there been evidence of abuse/neglect before now If the answer to question 3 is yes please explain the nature of the abuse/neglect. Names and addresses of other persons who may be willing to provide information about this case. Your relationship to child ren Reporter Action Recommended or Taken Yes No PLEASE CHECK THE APPROPRIATE RESPONSE I saw the child ren I heard about the child ren From whom have have not told the child s family of my concern and of my report to the Department. Names and addresses of other persons who may be willing to provide information about this case. Your relationship to child ren Reporter Action Recommended or Taken Yes No PLEASE CHECK THE APPROPRIATE RESPONSE I saw the child ren I heard about the child ren From whom have have not told the child s family of my concern and of my report to the Department. I willing NOT willing to tell the child s family of my concern and of my report to the Department. I am believe do NOT believe the child is in immediate physical danger. .

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