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Child Maltreatment Report

  1. 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.

  2. Place Alleged Events Occurred:
  3. Please specify

  4. REPORTING SOURCE

    Person completing the form

  5. Type of Reporter:
  6. ALLEGED VICTIM
  7. Gender
  8. Does the child have Native American Heritage?
  9. Interpreter needed?
  10. Does the child have any known disabilities?
  11. Additional Information
  12. Gender
  13. Does the child have Native American Heritage?
  14. Interpreter needed?
  15. Does the child have any known disabilities?
  16. Additional Information
  17. Gender
  18. Does the child have Native American Heritage?
  19. Interpreter needed?
  20. Does the child have any known disabilities?
  21. Additional Information
  22. Gender
  23. Does the child have Native American Heritage?
  24. Interpreter needed?
  25. Does the child have any known disabilities?
  26. Additional Information
  27. Gender
  28. Does the child have Native American Heritage?
  29. Interpreter needed?
  30. Does the child have any known disabilities?
  31. Additional Information
  32. Gender
  33. Does the child have Native American Heritage?
  34. Interpreter needed?
  35. Does the child have any known disabilities?
  36. Additional Information
  37. Gender
  38. Does the child have Native American Heritage?
  39. Interpreter needed?
  40. Does the child have any known disabilities?
  41. Additional Information
  42. Gender
  43. Does the child have Native American Heritage?
  44. Interpreter needed?
  45. Does the child have any known disabilities?
  46. ALLEGED PERPETRATOR
  47. Gender
  48. Type of Phone Number
  49. Additional Information
  50. Type of Phone Number
  51. Additional Information
  52. Type of Phone Number
  53. Interpreter needed?
  54. Does the perpetrator have any known disabilities?
  55. Additional Information
  56. Gender
  57. Type of Phone Number
  58. Additional Information
  59. Type of Phone Number
  60. Additional Information
  61. Type of Phone
  62. Interpreter Needed?
  63. Does the perpetrator have any known disabilities?
  64. Additional Information
  65. Gender
  66. Type of Phone Number
  67. Additional Information
  68. Type of Phone Number
  69. Additional Information
  70. Type of Phone Number
  71. Interpreter needed?
  72. Does the perpetrator have any known disabilities?
  73. Additional Information
  74. Gender
  75. Type of Phone Number
  76. Additional Information
  77. Type of Phone Number
  78. Additional Information
  79. Type of Phone Number
  80. Interpreter needed?
  81. Does the perpetrator have any known disabilities?
  82. FAMILY
  83. Type of Phone Number
  84. Additional Information
  85. Type of Phone
  86. Additional Information
  87. Type of Phone
  88. Do they have Native American Heritage?
  89. Interpreter needed?
  90. Type of Phone
  91. Additional Information
  92. Type of Phone
  93. Additional Information
  94. Type of Phone
  95. Do they have Native American Heritage?
  96. Interpreter needed?
  97. ADDITIONAL HOUSEHOLD MEMBERS & SIBLINGS
  98. Add Additional Household Members

    This could also include siblings not living in the household

  99. Do they have Native American Heritage?
  100. Is this person a child?
  101. Does the child have any known disabilities?
  102. Add Additional Household Members

    This could also include siblings not living in the household

  103. Do they have Native American Heritage?
  104. Is this person a child?
  105. Does the child have any known disabilities?
  106. Add Additional Household Members

    This could also include siblings not living in the household

  107. Do they have Native American Heritage?
  108. Is this person a child?
  109. Does the child have any known disabilities?
  110. Add Additional Household Members

    This could also include siblings not living in the household

  111. Do they have Native American Heritage?
  112. Is this person a child?
  113. Does the child have any known disabilities?
  114. Add Additional Household Members

    This could also include siblings not living in the household

  115. Do they have Native American Heritage?
  116. Is this person a child?
  117. Does the child have any known disabilities?
  118. Add Additional Household Members

    This could also include siblings not living in the household

  119. Do they have Native American Heritage?
  120. Is this person a child?
  121. Does the child have any known disabilities?
  122. Add Additional Household Members

    This could also include siblings not living in the household

  123. Do they have Native American Heritage?
  124. Is this person a child?
  125. Does the child have any known disabilities?
  126. Add Additional Household Members

    This could also include siblings not living in the household

  127. Do they have Native American Heritage?
  128. Is this person a child?
  129. Does this child have any known disabilities?
  130. Add Additional Household Members

    This could also include siblings not living in the household

  131. Do they have Native American Heritage?
  132. Is this person a child?
  133. Does this child have any known disabilities?
  134. Add Additional Household Members

    This could also include siblings not living in the household

  135. Do they have Native American Heritage?
  136. Is this person a child?
  137. Does this child have any known disabilities?
  138. 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.

  139. 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.

  140. In accordance with M.S. 260C.007, written reports received by Child Protection will be forwarded to the local Police Department or County Sheriff.
  141. Leave This Blank:

  142. This field is not part of the form submission.