Address No. Street 15c. City 16d. State 16e. Zip Code 16f. Phone No. 45 Private Agency Social Worker 46 Court Social Worker 47 Other Social Worker 48 FIS/ES Worker/Supervisor 49 Social Services Specialist/Manager CPS FC etc. 52 DHS Facility Personnel 55 Private Social Agency Personnel 56 Court Personnel DHS-3200 Rev. 2-12 Previous edition may be used. MS Word TO BE COMPLETED BY MEDICAL PERSONNEL WHEN PHYSICAL EXAMINATION HAS BEEN DONE 20. REPORT OF ACTUAL OR SUSPECTED CHILD ABUSE OR NEGLECT...
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