HENNEPIN COUNTY
HUMAN SERVICES PUBLIC HEALTH DEPARTMENT
‘SUSPECTED CHILD MALTREATMENT REPORT
Minnesota Statutes Section 626. 556, Subdivision 7:
‘Any professional who has knowledge of or
reasonable cause to believe a child fs being neglected or physical or sexually abused shall make an
oral report immediately by phone (o be followed as soon as possible by a report in writing.”
[osteReponsaincient Occurea: _05-04- 17] Yoder oa 05-04-17
Chi Protection Services: (e12) 240-3552 pres 1,
‘Child Protection Intake SW taking report: _'
amy Pe
NameotReporer; Kt\Stev\_ ENS
ancy ascress: 4:56) WW (019 St
“ALLEGED vier
Name of ia
i.
mtr
chite’s Schoot: (JIsmn Middle
(dice
Relationship to vietm: il 1ager
‘Agency School of Reporter: icon Middle Ginpol
Cptemer net? trooe English
Fax (612) 486-9581
150
SL OU
Pi Male CFemte
wie
cone
Name of Ci Bianaate Sex: C)Male (Female
Home Aasross: Phone
Race: [interpreter needea? Language:
Name of Ci : ‘itndate Sec Cale Female
Phone )
Clnterpreter nesses? Language
Chia’ Schoo! a
"ALLEGED PERPETRATOR
Name of Perpevator : Bithdate or Age: Sox: Cae Sk Femate
Address: Same OS" allted vii" -
Home Phone: (151 )335 Ml work Pnone-_( oie Ikeau Phones (ie) 2
Perpetrator Relationshipto Family orchits: udvclian (Adpp hve mow)
Suspected Chis Matratment Rept. 4SEF
tg (in? og
Sa a Birthdate or Age | Address —
We think therg other! children iv) the home rent I
aaa iaildete nome (par ents biolygi cat
[eS RATRERET—]n asns pint
Thi <1S being physically apused by his mom
ed Scratches on Wis neck trom her
nis mouth from her grablang I's
Nails and Surapes inside
face, He noted tis happens when Aad
different level of the home, “Hild
do his chores correctly
wounds and confivmed
wes
2 checked the
ynside Mis mnouctla
conten for his
when he
The School nu
Scratches an Wi Meck *
Child expressed Sincere
1S. refusing t go home from Stnool Toelay.
HOUse, “yen NLe
an
aig ells —_
tug sepals
Dae
‘hit Protection Screening — MC L965
lap ee leah Services Buin
wo South, Minnespot, MN S6818.1869.
In accordance with M.S. 628.556, Subdivision 7, written reports ree et ae i:
626.556, Subsvision 7, writen
vod by Chit 3 forward
Suspected Child Matstnent Repor-p.2