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The Dhs 3200 form serves a critical role in the reporting process for suspected child abuse or neglect in Michigan. It is designed to facilitate the collection of essential information from individuals who have observed or suspect that a child is being harmed or neglected. This form must be completed following an oral report made to the Michigan Department of Human Services (DHS). Key sections include details about the child or children involved, such as their names, birth dates, and addresses, as well as the names of the parents or guardians. Additionally, the form requires information about the alleged perpetrator and the circumstances surrounding the suspected abuse or neglect. Medical professionals are tasked with completing specific sections that pertain to physical examinations and any relevant medical documentation. Timely submission of this form to the Centralized Intake for Abuse & Neglect is crucial, as it initiates the necessary investigations to ensure the safety and well-being of the child. By providing a structured way to report concerns, the Dhs 3200 form plays a vital part in protecting vulnerable children within the community.

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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

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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 [email protected]

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
➤ PDF File

Form Specifications

Fact Name Details
Purpose The DHS-3200 form is used to report actual or suspected child abuse or neglect in Michigan.
Governing Law This form is governed by P.A. 238 of 1975, which mandates reporting requirements for child abuse and neglect.
Submission Method Reports can be submitted via mail, fax, or email to Centralized Intake for Abuse & Neglect.
Required Information Items 1-19 must be completed by the reporting person, while items 20-28 are for medical personnel only.
Confidentiality The identity of the reporting person is kept confidential to protect them from retaliation.
Contact Information If the complaint was phoned in, the reporting person must provide the log number, if known.
Disability Accommodations The form includes provisions for individuals with disabilities needing accommodations.
Legal Protections There are no penalties for reporting suspected abuse or neglect in good faith under Michigan law.

Dhs 3200: Usage Guidelines

Once the Dhs 3200 form is filled out, it must be submitted to the Centralized Intake for Abuse & Neglect. This can be done by mailing, faxing, or emailing the completed form. Ensure all relevant information is accurate and complete to facilitate the review process.

  1. Enter the date the form is being completed.
  2. List the child(ren) suspected of being abused or neglected, including available information. Note if the child has a disability.
  3. Provide the mother’s name (or mother substitute) and any relevant details. Indicate if she has a disability.
  4. Provide the father’s name (or father substitute) and any relevant details. Indicate if he has a disability.
  5. Enter the child(ren)’s address (No. & Street).
  6. Enter the city where the child(ren) resides.
  7. Provide the phone number of the household where the child(ren) live.
  8. Indicate the name of the alleged perpetrator of abuse or neglect.
  9. Describe the relationship of the alleged perpetrator to the child(ren).
  10. List the person(s) the child(ren) were living with when the abuse/neglect occurred.
  11. Enter the address where the abuse or neglect occurred.
  12. Describe the injury or conditions and the reason for suspicion of abuse or neglect.
  13. Select the source of complaint by checking the appropriate box.
  14. Provide the reporting person’s name and address, along with any additional reporting persons as needed.
  15. If applicable, complete items 20-28 for medical personnel regarding physical examinations and findings.

After completing the form, ensure it is sent to the appropriate address: Centralized Intake for Abuse & Neglect, or faxed or emailed as indicated. Double-check that all required sections are filled out to avoid delays.

Your Questions, Answered

What is the Dhs 3200 form?

The Dhs 3200 form is a report used in Michigan to document actual or suspected cases of child abuse or neglect. It is a crucial tool for ensuring the safety and well-being of children by allowing concerned individuals to report their observations and concerns to the Michigan Department of Human Services (DHS). This form serves as a follow-up to any oral reports made and must be completed and submitted to Centralized Intake for further investigation.

Who should fill out the Dhs 3200 form?

The form should be completed by any individual who suspects a child is being abused or neglected. This could include teachers, medical professionals, social workers, or even family members. It is essential that the reporting person provides as much detailed information as possible about the situation to facilitate a thorough investigation.

What information is required on the form?

The Dhs 3200 form requires a variety of information, including the names and birthdates of the child or children suspected of being abused, details about the alleged perpetrator, and a description of the injuries or conditions that raised suspicion. Additionally, the reporting person's contact information and relationship to the child are necessary. Items 20-28 are to be completed by medical personnel if a physical examination has been conducted.

How do I submit the Dhs 3200 form?

You can submit the Dhs 3200 form in several ways. It can be mailed to Centralized Intake for Abuse & Neglect at the specified address in Grand Rapids, Michigan. Alternatively, you may fax it to one of the provided fax numbers or email it to the designated DHS email address. Choose the method that is most convenient for you, ensuring that the form is sent promptly to avoid any delays in addressing the concerns.

What happens after I submit the Dhs 3200 form?

Once the Dhs 3200 form is submitted, the Centralized Intake team will review the information provided. If the report indicates a credible concern for a child's safety, an investigation will be initiated. This may involve contacting the reporting person for additional information or reaching out to other relevant parties to gather more details about the situation.

Is there a penalty for not reporting suspected child abuse or neglect?

While there is no direct penalty for failing to report suspected child abuse or neglect, it is important to understand the moral and legal obligations to protect children. In Michigan, certain professionals, such as teachers and healthcare providers, are mandated reporters, meaning they are legally required to report any suspicions of abuse or neglect. Failure to do so could result in professional consequences or legal action.

Can I remain anonymous when submitting the Dhs 3200 form?

Common mistakes

  1. Incomplete Information: Failing to provide all required details for each child can lead to delays. Ensure that names, birth dates, and addresses are fully entered.

  2. Incorrect Reporting Codes: Using the wrong reporting code can cause confusion. Double-check the source of the complaint and select the appropriate code from the provided list.

  3. Missing Signatures: Not signing the form or omitting necessary signatures from medical personnel can result in the form being rejected. Ensure that all required signatures are present.

  4. Failure to Attach Documentation: If there are medical examinations or additional evidence, failing to attach relevant documents can hinder the investigation. Always include necessary attachments when applicable.

Documents used along the form

The DHS 3200 form is a crucial document used to report suspected child abuse or neglect in Michigan. However, it is often accompanied by other forms and documents that provide additional context or information. Below are some commonly used documents that may accompany the DHS 3200 form.

  • Medical Examination Report: This document is completed by medical personnel and includes findings from a physical examination of the child. It may detail injuries, health conditions, and any signs of previous abuse or neglect, providing essential evidence to support the claims made in the DHS 3200 form.
  • Incident Report: Often created by law enforcement or social service professionals, this report outlines the circumstances surrounding the suspected abuse or neglect. It typically includes details such as the date, time, location, and nature of the incident, helping to create a comprehensive picture of the situation.
  • Family Assessment Form: This form evaluates the family environment and dynamics. It may include information about the child's living conditions, relationships with caregivers, and any previous incidents of abuse or neglect. This assessment helps authorities understand the broader context of the child's situation.
  • Referral for Services: When abuse or neglect is suspected, this document may be used to refer the family to appropriate support services. It outlines the specific needs of the child and family, such as counseling or rehabilitation programs, and aims to ensure that they receive the necessary assistance.

These accompanying documents enhance the understanding of each case and support the efforts of child protection services. Together with the DHS 3200 form, they play a vital role in ensuring the safety and well-being of children in Michigan.

Similar forms

The DHS 3200 form, used for reporting child abuse or neglect, shares similarities with several other important documents. Each of these forms serves a specific purpose in the realm of child welfare and safety. Here are five documents that are similar to the DHS 3200 form:

  • Child Abuse Reporting Form: This document is also designed for reporting suspected child abuse. It requires similar information about the child, the alleged perpetrator, and the circumstances surrounding the abuse or neglect.
  • Incident Report Form: Often used in schools or daycare settings, this form documents incidents involving children. Like the DHS 3200, it captures details about the child, the event, and any witnesses.
  • Medical Report for Child Abuse: This report is completed by medical professionals when a child is examined for signs of abuse. It parallels the DHS 3200 in that it includes details about the child’s injuries and the findings of the examination.
  • Child Protection Services Intake Form: This form is used by child protective services to gather initial information about a case. It includes similar sections for reporting concerns about a child’s safety and well-being.
  • Domestic Violence Incident Report: This document is used to report incidents of domestic violence, which may involve children. It shares the need for detailed descriptions of the situation and the individuals involved, much like the DHS 3200.

Dos and Don'ts

When filling out the DHS 3200 form, there are important guidelines to follow. Here are four things to keep in mind:

  • Do provide accurate and complete information for each child suspected of abuse or neglect.
  • Do include your contact information, so that authorities can reach you for further details if necessary.
  • Don't leave any sections blank unless they are specifically marked as optional.
  • Don't share personal opinions or assumptions about the situation; stick to the facts.

Misconceptions

Understanding the DHS 3200 form is crucial for anyone involved in reporting suspected child abuse or neglect. However, several misconceptions can create confusion. Here are nine common misconceptions about the form:

  • The DHS 3200 form is only for medical professionals. This form can be filled out by anyone who suspects child abuse or neglect, not just medical personnel.
  • You can report abuse without using the form. While initial reports can be made verbally, the DHS 3200 form serves as the official written follow-up and is required for documentation.
  • Filing the form guarantees immediate action. Submitting the form does not guarantee that immediate action will be taken. Investigations follow based on the information provided.
  • All reports are anonymous. While the identity of the reporter is kept confidential, it may not be completely anonymous if further investigation is needed.
  • You need to have all details before reporting. It’s better to report with incomplete information than to wait until you have all the details. Suspicions alone can trigger an investigation.
  • Only physical abuse needs to be reported. Neglect and emotional abuse are also serious and should be reported using the DHS 3200 form.
  • The form must be mailed only. In addition to mailing, the form can also be faxed or emailed to Centralized Intake, providing more options for submission.
  • The form is optional. Completing the DHS 3200 form is mandatory after an oral report of suspected abuse or neglect.
  • You can report abuse anonymously without any consequences. While your identity may be protected, false reporting can lead to legal repercussions.

Clearing up these misconceptions can help ensure that children at risk receive the protection they need. If you suspect abuse or neglect, it’s essential to take action and report it using the DHS 3200 form.

Key takeaways

Key Takeaways for Filling Out and Using the DHS 3200 Form:

  • Confirm if the complaint was phoned to DHS. If not, contact Centralized Intake immediately at 855-444-3911.
  • Complete items 1-19 on the form. Items 20-28 should only be filled out by medical personnel.
  • Provide the date the form is completed in the designated section.
  • List all child(ren) suspected of abuse or neglect, including their names, birth dates, and any disabilities that may require accommodations.
  • Include the names and addresses of the mother and father, or their substitutes, if applicable.
  • Document the name of the alleged perpetrator and their relationship to the child(ren).
  • Clearly describe the injuries or conditions that raise suspicion of abuse or neglect, along with the source of the complaint.
  • Submit the completed form to Centralized Intake by mail, fax, or email as specified in the instructions.