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State Form 54204 (R3 / 11-12)
(Complainant Information will be kept confidential according to 4-13-19-7)
Relationship to the child(ren):
Department of Child Services
County where agency is located:
Name of Family Case Manager, Supervisor or other staff involved:
Type of case Hotline Assessment / Investigation Ongoing case / CHINS Adoptions Other
Child / Children Informations
Information On Other Adults Involved
The DCS Ombudsman Bureau may receive, investigate, and attempt to resolve a complaint alleging that DCS, by action or omission, failed to protect the physical of mental health of safety of any child or failed to follow specific laws, rules, or written policies. Within this context, briefly describe your complaint.
Describe the DCS actions / inactions you believe resulted in the failure to protect the child(ren):
Describe the policy, rule or law you believe DCS did not follow:
List the steps you taken to resolve your complaint:
Is there any pending Court action regarding this matter or a pending Administrative Review? If so, please describe the status:
Please describe what you consider a reasonable resolution to your complaint:
Important: Pursuant to IC 4-13-19-7(3), except as necessary to resolve and investigate a complaint, we will not give your name to DCS without your permission. Can we use your name when discussing your complaint with DCS? If you are submitting electronically, please return the written consent include in the confirmation of receipt letter: Yes No
How did you find out about this office:
Date Signed (month, day, year):