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Get CT DCF-136 2002

) to the Hotline. 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 Male AGE OR BIRTH DATE Female CHILD’S ADDRESS NAME OF PARENTS OR OTHER PERSON RESPONSIBLE ADDRESS PHONE NUMBER PHONE NUMBER DATE PROBLEM(S) NOTED FOR CHILD’S CARE WHERE IS THE CHILD STAYING PRESENTLY IF NOT AT HOME? NAME OF HOTLINE WORKER TO WHOM ORAL REPORT DATE OF ORAL REPORT DATE AND TIME OF SUSPECTED ABUSE/NEGLECT WAS.

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