Children Services Report Form

Has the PCSA received the written request from the superintendent of public instruction for the information reported in this form?:
Does the prosecuting attorney intend to prosecute the alleged perpetrator?:

Has the prosecuting attorney determined this information may not be released?:
If the prosecuting attorney intends to prosecute, is there written authorization from the prosecuting attorney to release certain information?:

Section I: Incident Information

Has Local Law Enforcement been involved:

Section II: Perpetrator Information

Has Medical Treatment Been Provided to the Alleged Perpetrator:

Section III: Alleged Child Victim

Has Medical Treatment Been Provided to the Alleged Child Victim:

Section IV: Summaries

If the alleged perpetrator in the present case has had any prior reports in which the agency determined that physical or sexual abuse occurred, please provide a summary. The summary shall include a chronology of those reports, final disposition of investigations in response to reports, or status of any investigations not yet complete.
Summary of interviews with the child and the contact information of any entity besides the public children services agency that conducted the interview with the child.
Please provide a summary of any interviews with individuals, other than the alleged child victim and alleged perpetrator, whom the agency has determined to be important to the investigation. However, the PCSA shall not provide information regarding the identity of person making the report without the person’s written permission to release such information.
To the extent permitted by law, please provide copies of any written correspondence between the alleged child victim and the alleged perpetrator.
Will you be providing additional documentation or correspondence?:
How will you provide the additional documentation?:


The information contained in this form is confidential and unauthorized dissemination of the information is a misdemeanor of the fourth degree pursuant to section 2151.99 of the Revised Code.

Contact Information

25 South Front Street, Mailstop 104,
Columbus, OH 43215-4183
(P) 614-466-5638, Fax:
(F) 614-995-3752, e-mail:

Last Modified: 5/8/2013 3:36:45 PM