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
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04
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07
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46
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52
53
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57
58
59
Minutes
AM
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: