MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION SAFE-CARE Provider Evaluation Referral
Report Date:
Incident Number:
Date of Referral:
CASE DATA
CHILD
CHILD’S NAME	DATE OF BIRTH	AGE	GENDER
ALLEGED PERPETRATOR(S) UNKNOWN
NAME	RELATIONSHIP
NAME	RELATIONSHIP
WORKER
WORKER NAME	PHONE NUMBER	COUNTY
WORKER’S EMAIL ADDRESS	SUPERVISOR’S EMAIL
ALLEGATIONS
CATEGORY OF ABUSE/NEGLECT (Check all that apply) PHYSICAL ABUSE SEXUAL ABUSE EMOTIONAL ABUSE NEGLECT
REPORTED CONCERN
ADDITIONAL INFORMATION OBTAINED FROM CONTACTS
MEDICAL INFORMATION
Has the child received medical attention for these allegations? Yes No
If yes, treating physician’s information:
Name:	Phone Number	Hospital:
Does The Child Have An Injury? Yes No Unknown
Do You Have Any Medical Records For This Incident Yet? Yes (Attach To Referral) No
Explain/describe any injuries or suspicion of injury, including location and any possible mechanism of injury. If there are no concerns of injury, are there any other medical concerns related to the allegation?
RECOMMENDATIONS FOR FOLLOW UP MEDICAL EVALUATION (TO BE COMPLETED BY PHYSICIAN)
no medical/forensic evaluation required based on information provided above medical exam by general practitioner medical examination by a safe-care provider needed medical examination by a board certified child abuse pediatrician needed case review by a safe-care provider needed
Further recommendations for medical treatment:
SIGNATURE OF PHYSICIAN	DATE