Suspected Child Abuse/Neglect Report Form

The Suspected Child Abuse/Neglect Report Form is a critical tool used to protect the well-being and safety of children within the Navajo Nation. This form allows individuals to report any concerns or suspicions of child abuse, neglect, or endangerment. By providing detailed information, the form helps ensure that each case is appropriately investigated and addressed in accordance with Navajo laws and customs, safeguarding the rights of children and supporting families in need. Accurate and timely reporting is essential to uphold the welfare and protection of vulnerable children within the community.

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Domestic Violence
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What office do you want this form to be sent to?(Required)

Are you a mandatory reporter, bystander or self reporting?(Required)

§1117. Duty to report child abuse; penalty for failure to report

Any medical provider, school personnel, law enforcement, law enforcement official or social worker, acting n his or her official capacity or any appointed or elected Naat’aanii, having a reason to believe that any abuse or neglect ha been inflicted upon a child shall report the matter immediately to a Law Enforcement official or the Division.
Any other person having reason to believe that a child has been subjected to serious injury or injuries have been inflicted upon the child as a result of abuse or neglect shall report the matter immediately to a Law Enforcement official or the Division.
A lay person who provides a report of abuse or neglect may at his/her discretion remain anonymous.
Any person failing, neglecting or refusing to report a suspected case of child abuse or neglect pursuant to this Section may be subject to civil sanction including but not limited to a penalty not to exceed five-hundred dollars ($500.00)

Any person making a report to the Department shall be immune from civil or criminal liability. See 2 N.N.C. Subsection §1118(B) for more information.

§1118. Waiver of Privilege and Immunity

In any proceeding alleging child abuse or neglect under this Chapter resulting from a report submitted under §1117, or in any proceeding in which the report or any part of its contents is sought to be introduced in evidence, the report or its contents or any facts related thereto or to the condition of the child who is the subject of the report shall not be subject to a physician-patient privilege or similar privilege, rule or law against disclosure.
Any person reporting an instance of suspected child abuse or neglect or participating in a judicial proceeding brought as a result of a report submitted under §1117 shall be presumed to be acting in good faith and shall be immune from civil or criminal liability, unless a finding is made that the person acted in bad faith or with malicious purpose.
The Division shall be immune from civil or criminal liability for services rendered pursuant to this Chapter, unless the Division acted with gross negligence or malice or unless the Division has been charged with or is suspected of abusing, abandoning or neglecting the child in question.

Name(Required)

First Last

Enter Your Email(Required)

Enter Your Phone(Required)

Enter Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Referred Individual's Information

Name(Required)

First Last

Gender(Required)

Date of Birth

MM slash DD slash YYYY

School

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Additional Directions to Home

Referred Individual's Parent, Legal Guardian or Custodian

Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Home Address

Street Address Address Line 2 City State ZIP Code

Phone

Referred Individual's Other Household Members

Name

First Last

Gender

Relationship to Referred Individual

Name

First Last

Gender

Relationship to Referred Individual

Name

First Last

Gender

Relationship to Referred Individual

Allegation(Required)

Physical abuse

Sexual abuse

Neglect

Alcohol Abuse (parent)

Alcohol Abuse (child)

Drug Abuse (parent)

Drug Abuse (child)

Abandonment

Other – specify

If Other, please specify:

Report Details(Required)

If you have additional documentation, please upload here:

Drop files here or

Max. file size: 40 MB.

Has this child been removed from their home by Navajo Nation Temporary Custody Notice?(Required)

If Other, please explain:

What is the priority of this report?(Required)

Would the worker going onsite have any concerns? (ie: dangerous situation or need police escort)(Required)

If Yes, please explain:

I agree to the privacy policy.