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Get ND SFN 960 2015-2024

REPORT OF SUSPECTED CHILD ABUSE OR NEGLECT Clear Fields NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES CHILDREN AND FAMILY SERVICES SFN 960 6-2015 Name of Child ren Age or Birthdate IDENTIFYING INFORMATION Name of Parent s /Caretaker Telephone Number Address City State ZIP Code Name of Subject Person s Suspected to be Causing Maltreatment Give nature and extent of the suspected abuse or neglect including any information of previous abuse or neglect family composition and any other information which may be helpful in protecting the health and welfare of the child ren. If additional space is needed attach additional pages. BE SPECIFIC. ANSWER WHO WHAT WHEN WHY HOW OFTEN. Name of Reporter Reporter s Relationship to Children Telephone Number Signature of Reporter Date AGENCY USE ONLY Date and Time Received by Agency Name of Intake Social Worker Source Report Number Assessment Number Case Number Name of Social Worker Assigned to Case Received By In Person Telephone Date of Entry Written Initial Category A B C Please submit the completed form to the county social service office where the child is currently physically located* Contact information for county social service offices can be found at www. If additional space is needed attach additional pages. BE SPECIFIC. ANSWER WHO WHAT WHEN WHY HOW OFTEN. Name of Reporter Reporter s Relationship to Children Telephone Number Signature of Reporter Date AGENCY USE ONLY Date and Time Received by Agency Name of Intake Social Worker Source Report Number Assessment Number Case Number Name of Social Worker Assigned to Case Received By In Person Telephone Date of Entry Written Initial Category A B C Please submit the completed form to the county social service office where the child is currently physically located* Contact information for county social service offices can be found at www. .

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