Abuse and Neglect Intake Report for Child Abuse/Neglect Pueblo of Sandia Tribal Social Services Name of Reporter: Date of Report: Reporters Address: Reporters Address: Reporters Address: Reporters Address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Reporters Home Phone: Reporters Cell Phone: Reporters Work Phone: Relationship to Family: Remain Anonymous: Yes No Are you Law Enforcement Personnel? Yes No Tribe: Date Incident Occurred: Where did the incident occur? Was alcohol/substance abuse involved? if so which? Parent/Guardian's Name: Parent/Guardian's Name: First First Last Last Parent/Guardian's Address: Parent/Guardian's Address: Parent/Guardian's Address: Parent/Guardian's Address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Parent/Guardian's Home Phone: Parent/Guardian's Cell Phone: Parent/Guardian's Work Phone: List Child(ren) Individually: Name: Gender: Race: W: WhiteB: BlackLH: Latino/HispanicAP: Asian Pacific IslanderNA: Native AmericanU: Unable to Determine Date of Birth(DOB) Age: Role: AV: Alleged VictimAP: Alleged PerpetratorHM: Household MemberPC: Primary CaretakerRN: Reporter NameCC: Collateral Contact Allegation: PN: Physical NeglectPA: Physical AbuseEA: Emotional AbuseEN: Emotional NeglectSA: Sexual AbuseOther: Any others Alleged Perpetrator(s) List School if child(ren) are school age: Name of School: Address: Phone Number: Grade: plus1 Add minus1 Remove Mother's Information Name Name First First Last Last Date of Birth Age Lives in the home? Yes No Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone Number: Work Phone Number: Cell Phone Number: Resident of Pueblo of Sandia Yes No Tribal Affiliation: Father's Information Name Name First First Last Last Date of Birth Age Lives in the home? Yes No Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone Number: Work Phone Number: Cell Phone Number: Resident of Pueblo of Sandia Yes No Tribal Affiliation: If Alleged Perpetrator is anyone else other than parent/guardian list them here: Name Name First First Last Last Date of Birth: Age Lives in the home? Yes No Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone Number: Work Phone Number: Cell Phone Number: Resident of Pueblo of Sandia Yes No Tribal Affiliation: Relationship to family: plus1 Add minus1 Remove Is the alleged perpetrator a relative that lives outside the home? Yes No Does the relative or alleged perpetrator entrusted with the care of the child have a significant degree of parental-type responsibility for the child? Yes No If yes, what is the duration of the care provided by the adult? 0 of 1000 max characters If yes, what is the frequency of the care provided by the adult? 0 of 1000 max characters What is the location in which that care is provided? 0 of 1000 max characters What is the decision-making authority (if any) that has been granted to the adult/relative? 0 of 1000 max characters Address and phone number(s) of all household members, including the length of time at current address, include any former addresses and phone numbers if possible. 0 of 1000 max characters Driving directions to the family home: 0 of 1000 max characters Is the alleged perpetrator/household member/or parents affiliated with the military? If so who and what is the affiliation? 0 of 1000 max characters Family's primary language Collateral contacts (others who may have knowledge about the abuse/neglect; include names, phone numbers, address). 0 of 1000 max characters Do you have infomration about the child(ren) maternal/paternal relatives (include names, phone numbers, address). 0 of 1000 max characters Has the family ever been involved with Tribal Social Services before? Is there a current case to your knowledge? 0 of 1000 max characters Below please describe the events that toook place, injuries, conditions, and reasons for suspicion of abuse/neglect. (It is important to list as much detail as possible such as dates, times, potential witnesses). Any information regarding the reporter is protected by confidentiality. 0 of 1000 max characters If you are human, leave this field blank. Submit
