If you believe that the child/children is/are in imminent danger, as defined by WV Code § 49-1-201, report immediately by phone to 1-800-352-6513, option 2.

This form and reporting process is for use by mandated reporters to report suspected cases of child abuse or neglect only.

See WV Code § 49-2-803 for more information on mandated reporting.

Reporter Information

Name (First and Last)*

Relationship to Victim*

Date/Time Submitted*

Phone*

Mailing Address*

Family Information

Name (Last Name Only)*

Address (including City, State, Zip)*

Phone Number*

Directions to Home*

Caregiver Information

Name*

DoB/Approximate Age*

Sex*

Phone*

Caregiver Employer*

Caregiver Employer Address*

Caregiver Employer Phone Number*

Where is the caregiver now?*

How long will the caregiver be there?*

Child Information

Name*

School/Daycare/Grade*

DoB/Approximate Age*

Sex*

Race*

Where is/are the child(ren) located now?*

How long will the child(ren) be there?*

Other Persons Living in the Home:

Name*

DoB/Approximate Age*

Race*

Absent Parents:

Name*

Address/Whereabouts*

Phone*

Other Sources of Information About the Family:

Name*

Address*

Knowledge of Family/Situation*

Referral Information:

Do the children have injuries now?* Yes No

Allegation Type:* Abuse Neglect Both

What are the surrounding circumstances accompanying the alleged abuse or neglect being report. Describe how the child(ren) is/are unsafe. Please be specific.* 0/10,000 characters

*Required fields