Capital Region ESD 113 Sound to Harbor Head Start/ECEAP

Capital Region ESD 113 Sound to Harbor Head Start/ECEAP Serving Grays Harbor, Mason and Thurston Counties A d m i n i s t r a t i o n O f f i c e 6005 Tyee Drive SW, Tumwater, WA 98512 Office: 360-464-6800 FAX: 360-464-6903

CHILD ABUSE AND NEGLECT CPS LETTER CHILD INFORMATION: Name of child: Birth date: Siblings: (names and ages) Parents’ names: Address: Phone number: REASON FOR REFERRAL: Describe behaviors and observations that lead you to suspect abuse and/or neglect. What happened? Where and when? Date of abuse and/or neglect. Date of observation or disclosure. Nature and extent of injuries. Statements made by child or parent(s).

Actions taken by staff:

Previous injuries or statements:

REPORT MADE: Report taken Informational call Parent notified of report made: Yes No Name of CPS Intake Worker: Date / Time: What the CPS Worker said:

Signature of Reporter: Position: Reporter requested a follow up call by CPS: Yes No Other MAIL ORIGINAL REPORT TO YOUR LOCAL CPS OFFICE: Grays Harbor County DCFS/CPS 415 W Wishkah, Suite 2C Aberdeen, WA 98520 888-713-6115 360-537-4355 Kitsap County DCFS/CPS 3423-6th Street, Suite 217 Bremerton, WA 98312 888-713-6115 Mason County DCFS/CPS PO Box 1127 Shelton, WA 98584 888-713-6115 360-432-2050 Pierce County DCFS/CPS 1949 So. State St 3rd Floor Tacoma, WA 98405 888-713-6115 253-983-6200 Tumwater DCFS/CPS 6860 Capitol Blvd, Bldg 2 Tumwater, WA 98504 888-713-6115 360-725-6701 Original: CPS Copy: Center Director to forward to the site’s Mental Health Specialist, and the center’s Childcare Licensor

Capital Region Educational Service District 113 does not discriminate with respect to race; creed; color; national origin; religion; age; sex; marital status; pregnancy; sexual orientation; gender expression or identity; genetic information; honorably discharged veteran or military status; the presence of any sensory, mental or physical disability; the use of a trained guide dog or service animal; or any other basis protected by state and/or federal law in its programs, activities, employment procedures and personnel practices.

Forms\Admin\A-80 CAN Report-electronic HS/E Staff: This report layout is for typing. See other layout for handwriting a report. (Rev 7/7/16)