Clone of Child Abuse Hotline Report 22-23

1
School Name* This field is required.
Early Childhood Center
Columbian Elementary School
Fairview Elementary School
Mark Twain Elementary School
Pleasant Valley Elementary School
Steadley Elementary School
Carthage Intermediate Center
Carthage 6th Grade Center
Carthage Junior High School
Carthage High School
Carthage Technical Center
Virtual Learning Center
2
Building Administrator's Name* This field is required.
First Name
Last Name
3
Building Administrator's Email* This field is required.
example@example.com
4
Building Counselor's Name* This field is required.
First Name
Last Name
5
Building Counselor's Email* This field is required.
example@example.com
6
Today's Date* This field is required.
Date
Month
Day
Year
7
Student's Name* This field is required.
First Name
Last Name
8
Student's Race* This field is required.
9
Student's MOSIS #* This field is required.
10
Parent's Name 01* This field is required.
First Name
Last Name
11
Parent's Name 02
First Name
Last Name
12
Parent's Phone Number* This field is required.
Please enter a valid phone number.
13
Person Reporting* This field is required.
First Name
Last Name
14
Person Reporting Email* This field is required.
example@example.com
15
Date of Event* This field is required.
Date
Month
Day
Year
16
Time of Event* This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
17
Circumstances* This field is required.
Huge
Large
Normal
Small
Ok
Ok
18
Report Status* This field is required. Ask the caseworker what steps are going to be taken by the Children's Division in response to your call.
Huge
Large
Normal
Small
Ok
Ok
19
Caseworker # Ask for this number when you call the hotline.
20
Reporter's Signature* This field is required.
Clear
Should be Empty: