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Get Suspected Child Abuse & Neglect In State Institutions - Kansas ...

Ease complete entire form. You may attach additional sheets if necessary. Immediately print and fax this form to (785) 291-3875. Questions (785) 296-7968. After hours emergency (785) 296-8262 and fax form to (785) 296-6296 1 GENERAL INCIDENT INFORMATION State Institution Unit or POD Location Date of Incident Time of Incident Shift 2 SUBJECT INFORMATION Subject 1 Name Male SSN Date of Birth Female Juvenile Offender Juvenile Correctional Officer Shift Injuries Subject 2 Name Male SSN.

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