Form Center

2. Benton County Human Services

   Suspected Maltreatment Report

   531 Dewey Street

   P.O. Box 740 

   Foley, MN 56329

   Phone: 320-968-5087 or 1-800-530-6254

   Fax: 320-968-5330

   
   

   Minnesota Statute Section 626.556, Subdivision 7: “Any professional who has knowledge of or reasonable cause to believe a child is being neglected or physically or sexually abused shall make an oral report immediately by phone (within 24 hours) to be followed as soon as possible by a report in writing (within 72 hours).”

   Please complete all fields unless the information is unknown.

4. Date Reported Incident Occurred:
5. Today's Date:
   Today's Date:
7. Place Alleged Events Occurred:
9. City
10. State
11. County
13. Setting Where Events Occurred
    -- Select One --FamilyFacilityOther
14. Other

    Please specify

18. REPORTING SOURCE

    Person completing the form

20. Type of Reporter:

    1. Mandated
    2. Voluntary
22. Name of Reporter
23. Relationship to Victim
25. Agency/School of Reporter
27. Address
29. City
30. State
31. ZIP Code
33. Phone Number*
34. Fax Number
38. ALLEGED VICTIM
40. Name
41. Birthdate
42. Gender

    1. Male
    2. Female
    3. Other/rather not say
44. Home Address
45. City
46. State
47. ZIP Code
49. Phone Number
50. Current custody arrangement
51. Race
52. Does the child have Native American Heritage?

    1. Yes
    2. No
    3. Unsure
54. Language
55. Interpreter needed?

    1. Yes
    2. No
    3. Unsure
57. Does the child have any known disabilities?

    1. Yes
    2. No
    3. Unsure
58. Please list diagnosis or describe their disability
60. Child's School
62. Additional Information

    1. Add Additional Alleged Victim
64. Alleged Victim - Name
65. Birthdate
66. Gender

    1. Male
    2. Female
    3. Other/rather not say
68. Home Address
69. City
70. State
71. ZIP Code
73. Phone Number
74. Current custody arrangement
75. Race
76. Does the child have Native American Heritage?

    1. Yes
    2. No
    3. Unsure
78. Language
79. Interpreter needed?

    1. Yes
    2. No
    3. Unsure
81. Does the child have any known disabilities?

    1. Yes
    2. No
    3. Unsure
82. Please list diagnosis or describe their disability
84. Child's School
86. Additional Information

    1. Add Additional Alleged Victim
88. Alleged Victim - Name
89. Birthdate
90. Gender

    1. Male
    2. Female
    3. Other/rather not say
92. Home Address
93. City
94. State
95. ZIP Code
97. Phone Number
98. Current custody arrangement
99. Race
100. Does the child have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
102. Language
103. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
105. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
106. Please list diagnosis or describe their disability
108. Child's School
110. Additional Information

     1. Add Additional Alleged Victim
112. Alleged Victim - Name
113. Birthdate
114. Gender

     1. Male
     2. Female
     3. Other/rather not say
116. Home Address
117. City
118. State
119. ZIP Code
121. Phone Number
122. Current custody arrangement
123. Race
124. Does the child have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
126. Language
127. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
129. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
130. Please list diagnosis or describe their disability
132. Child's School
134. Additional Information

     1. Add Additional Alleged Victim
136. Alleged Victim - Name
137. Birthdate
138. Gender

     1. Male
     2. Female
     3. Other/rather not say
140. Home Address
141. City
142. State
143. ZIP Code
145. Phone Number
146. Current custody arrangement
147. Race
148. Does the child have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
150. Language
151. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
153. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
154. Please list diagnosis or describe their disability
156. Child's School
158. Additional Information

     1. Add Additional Alleged Victim
160. Alleged Victim - Name
161. Birthdate
162. Gender

     1. Male
     2. Female
     3. Other/rather not say
164. Home Address
165. City
166. State
167. ZIP Code
169. Phone Number
170. Current custody arrangement
171. Race
172. Does the child have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
174. Language
175. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
177. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
178. Please list diagnosis or describe their disability
180. Child's School
182. Additional Information

     1. Add Additional Alleged Victim
184. Alleged Victim - Name
185. Birthdate
186. Gender

     1. Male
     2. Female
     3. Other/rather not say
188. Home Address
189. City
190. State
191. ZIP Code
193. Phone Number
194. Current custody arrangement
195. Race
196. Does the child have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
198. Language
199. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
201. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
202. Please list diagnosis or describe their disability
204. Child's School
206. Additional Information

     1. Add Additional Alleged Victim
208. Alleged Victim - Name
209. Birthdate
210. Gender

     1. Male
     2. Female
     3. Other/rather not say
212. Home Address
213. City
214. State
215. ZIP Code
217. Phone Number
218. Current custody arrangement
219. Race
220. Does the child have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
222. Language
223. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
225. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
226. Please list diagnosis or describe their disability
228. Child's School
232. ALLEGED PERPETRATOR
234. Name of Perpetrator
236. Perpetrator's Relationship to Family or Child
238. Birthdate
239. Gender

     1. Male
     2. Female
     3. Other/rather not say
241. Home Address
242. City
243. State
244. ZIP Code
246. Phone Number
247. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
248. Additional Information

     1. Add Additional Phone Number
250. Phone Number
251. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
252. Additional Information

     1. Add Additional Phone Number
254. Phone Number
255. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
257. Race
258. Language
259. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
261. Does the perpetrator have any known disabilities?

     1. Yes
     2. No
     3. Unsure
262. Please list diagnosis or describe disability
264. Additional Information

     1. Add Additional Alleged Perpetrator
266. Name of Perpetrator
268. Perpetrator's Relationship to Family or Child
270. Birthdate
271. Gender

     1. Male
     2. Female
     3. Other/rather not say
273. Home Address
274. City
275. State
276. ZIP Code
278. Phone Number
279. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
280. Additional Information

     1. Add Additional Phone Number
282. Phone Number
283. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
284. Additional Information

     1. Add Additional Phone Number
286. Phone Number
287. Type of Phone

     1. Home
     2. Work
     3. Cellphone
289. Race
290. Language
291. Interpreter Needed?

     1. Yes
     2. No
     3. Unsure
293. Does the perpetrator have any known disabilities?

     1. Yes
     2. No
     3. Unsure
294. Please list diagnosis or describe disability
296. Additional Information

     1. Add Additional Alleged Perpetrator
298. Name of Perpetrator
300. Perpetrator's Relationship to Family or Child
302. Birthdate
303. Gender

     1. Male
     2. Female
     3. Other/rather not say
305. Home Address
306. City
307. State
308. ZIP Code
310. Phone Number
311. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
312. Additional Information

     1. Add Additional Phone Number
314. Phone Number
315. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
316. Additional Information

     1. Add Additional Phone Number
318. Phone Number
319. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
321. Race
322. Language
323. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
325. Does the perpetrator have any known disabilities?

     1. Yes
     2. No
     3. Unsure
326. Please list diagnosis or describe disability
328. Additional Information

     1. Add Additional Alleged Perpetrator
330. Name of Perpetrator
332. Perpetrator's Relationship to Family or Child
334. Birthdate
335. Gender

     1. Male
     2. Female
     3. Other/rather not say
337. Home Address
338. City
339. State
340. ZIP Code
342. Phone Number
343. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
344. Additional Information

     1. Add Additional Phone Number
346. Phone Number
347. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
348. Additional Information

     1. Add Additional Phone Number
350. Phone Number
351. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
353. Race
354. Language
355. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
357. Does the perpetrator have any known disabilities?

     1. Yes
     2. No
     3. Unsure
358. Please list diagnosis or describe disability
362. FAMILY
364. Mother's Name
365. Birthdate
367. Home Address
368. City
369. State
370. ZIP Code
372. Phone Number
373. Type of Phone Number

     1. Home
     2. Work
     3. Cellphone
374. Additional Information

     1. Add Additional Phone Number
376. Phone Number
377. Type of Phone

     1. Home
     2. Work
     3. Cellphone
378. Additional Information

     1. Add Additional Phone Number
380. Phone Number
381. Type of Phone

     1. Home
     2. Work
     3. Cellphone
383. Race
384. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
385. Language
386. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
388. Father's Name
389. Birthdate
391. Home Address
392. City
393. State
394. ZIP Code
396. Phone Number
397. Type of Phone

     1. Home
     2. Work
     3. Cellphone
398. Additional Information

     1. Add Additional Phone Number
400. Phone Number
401. Type of Phone

     1. Home
     2. Work
     3. Cellphone
402. Additional Information

     1. Add Additional Phone Number
404. Phone Number
405. Type of Phone

     1. Home
     2. Work
     3. Cellphone
407. Race
408. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
409. Language
410. Interpreter needed?

     1. Yes
     2. No
     3. Unsure
412. ADDITIONAL HOUSEHOLD MEMBERS & SIBLINGS
414. Add Additional Household Members

     This could also include siblings not living in the household

     1. Check to add information
416. Name
417. Address
419. Birthdate
420. Relationship to victim(s)
421. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
422. Is this person a child?

     1. Yes
     2. No
424. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
425. Please list diagnosis or describe disability:
427. Add Additional Household Members

     This could also include siblings not living in the household

     1. Add Additional Household Member
429. Name
430. Address
432. Birthdate
433. Relationship to victim(s)
434. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
435. Is this person a child?

     1. Yes
     2. No
437. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
438. Please list diagnosis or describe disability:
440. Add Additional Household Members

     This could also include siblings not living in the household

     1. Add Additional Household Member
442. Name
443. Address
445. Birthdate
446. Relationship to victim(s)
447. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
448. Is this person a child?

     1. Yes
     2. No
450. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
451. Please list diagnosis or describe disability:
453. Add Additional Household Members

     This could also include siblings not living in the household

     1. Add Additional Household Member
455. Name
456. Address
458. Birthdate
459. Relationship to victim(s)
460. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
461. Is this person a child?

     1. Yes
     2. No
463. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
464. Please list diagnosis or describe disability:
466. Add Additional Household Members

     This could also include siblings not living in the household

     1. Add Additional Household Member
468. Name
469. Address
471. Birthdate
472. Relationship to victim(s)
473. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
474. Is this person a child?

     1. Yes
     2. No
476. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
477. Please list diagnosis or describe disability:
479. Add Additional Household Members

     This could also include siblings not living in the household

     1. Add Additional Household Member
481. Name
482. Address
484. Birthdate
485. Relationship to victim(s)
486. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
487. Is this person a child?

     1. Yes
     2. No
489. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
490. Please list diagnosis or describe disability:
492. Add Additional Household Members

     This could also include siblings not living in the household

     1. Add Additional Household Member
494. Name
495. Address
497. Birthdate
498. Relationship to victim(s)
499. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
500. Is this person a child?

     1. Yes
     2. No
502. Does the child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
503. Please list diagnosis or describe disability:
505. Add Additional Household Members

     This could also include siblings not living in the household

     1. Add Additional Household Member
507. Name
508. Address
510. Birthdate
511. Relationship to victim(s)
512. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
513. Is this person a child?

     1. Yes
     2. No
515. Does this child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
516. Please list diagnosis or describe disability:
518. Add Additional Household Members

     This could also include siblings not living in the household

     1. Add Additional Household Member
520. Name
521. Address
523. Birthdate
524. Relationship to victim(s)
525. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
526. Is this person a child?

     1. Yes
     2. No
528. Does this child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
529. Please list diagnosis or describe disability:
531. Add Additional Household Members

     This could also include siblings not living in the household

     1. Add Additional Household Member
533. Name
534. Address
536. Birthdate
537. Relationship to victim(s)
538. Do they have Native American Heritage?

     1. Yes
     2. No
     3. Unsure
539. Is this person a child?

     1. Yes
     2. No
541. Does this child have any known disabilities?

     1. Yes
     2. No
     3. Unsure
542. Please list diagnosis or describe disability:
546. Alleged Maltreatment Description
548. Additional Documentation

     If there are photos or additional information to go along with the report, they should be emailed to Intake@co.benton.mn.us.

550. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
552. Electronic Signature
553. Report Date:
     Report Date:
555. In accordance with M.S. 260C.007, written reports received by Child Protection will be forwarded to the local Police Department or County Sheriff.
Leave This Blank:


557. 1. Receive an email copy of this form.
558. Email address

     This field is not part of the form submission.

559. Submit

* indicates a required field