Mandatory Reporter Notification of Report Filed

Mandatory Reporter Notification of Report Filed

Thank you for fulfilling your critical role as a mandatory reporter. Your work helps protect and restore the lives of children.
Completing this notification form enables GSOSW to follow up on all reports filed regarding Girl Scouts in our care. We sincerely appreciate everything you do to support girls in our organization.
Contact information for person who filed the report (your information):
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Your role at GSOSWSU
Information about the Child, for whom you filed the report:
Name of the child

First NameLast Name
Date you observed evidence of abuse or neglect

MonthDayYear
Date
Details of the suspected abuse or neglect, which prompted you to file a report
Whereabouts of the child, if known
Date you filed the report

MonthDayYear
Date
State organization you contacted to file the report
If you were given a case number from DHS or CPS, please provide that here.
Should be Empty:

Contact information for person who filed the report (your information):