Child Abuse Pediatrics Consult

Emergent consults please page the child abuse pediatrician on call directly by dialing (317) 312-2911 and then entering your complete phone number (including *extension) followed by the #sign. You may also reach the child abuse pediatrician by paging through the operator at 317-944-5000.

DO NOT ASK FOR THE "PEDS DOCTOR." (Almost every doctor at Riley is a Peds doctor = pediatrician).

For non-emergent consultations please call the office at (317) 274-7401 and let us know you have a consult.

(Note: For sexual abuse concerns call the Pediatric Center of Hope – (317) 274-7377 and DO NOT USE this form)
Today's Date
Date of DCS Report
DCS FCM
County
Phone Number
Fax Number
Phone Ext
DCS FCM Email
DCS Supervisor
LE Contact
MAGIK #
Child's Name
DOB
Age
Mother's Name
Father's Name
Name of Hospital
Physician
Location of Child
Brief description of the case (Date, Caregiver at time of injury, explanation given by all parties involved i.e. child, parent, caregiver, etc):
Please Explain:
Please Explain:
Please Explain:
Please Explain:
Please Explain:
Please Explain:
Please Explain:
Injuries Identified (Any Known Pre-Existing Medical Conditions, Current Condition):
What laboratory or x-ray tests were done, if any?
Prior DCS history for abuse or neglect?
Prior DCS history details:
Previous childhood injuries/deaths?
Previous childhood injuries/deaths details:

DV/IPV

Remember that children in homes in which there is DV/IPV are 40-60 times more likely to be victims of maltreatment themselves. (Thackeray et al., 2010)
Current incident involves allegation of DV?
History of DV occurring in the home?
Child was physically injured (Dropped, Pulled, Thrown, Hit) as result of DV incident?
Child witnessed (Heard And/Or Saw) DV incident?
Law enforcement was involved at scene of DV Incident?
If the answer to any of the above items is yes, please explain:

General Concerns

Does the parent of the child have a history of victimization as a child?
How concerned are you about the child's overall safety in the environment where the incident occurred?
How concerned are you that the injury is inflicted/Maltreatment?
Additional information

Pets

History of animals being purposely harmed/killed in the household?
If child has injuries, was a pet blamed for causing them?
If the answer to any of the above items is yes, please explain:

Siblings

Name
DOB
Current Location
Medical Eval Done?
Name
DOB
Current Location
Medical Eval Done?
Name
DOB
Current Location
Medical Eval Done?
Which Child Protection Program Team Member did you speak with? To facilitate the referral, remember to CALL and speak with to a Child Protection Team Member before you submit your referral.
Other CPP Member:
Voicemail Date/Time:
What are your questions-how can we help? If you have already spoken to a CPP member and you have no additional questions, please indicate you have no additional questions.

Non-emergent consults: contact the office at 317-274-7401 (Monday – Friday 8-4)

All cases: this form must be sent through this secured form or faxed (317-278-2587)

Any additional information such as photos, records, release of information, etc. can be sent via email to iucpp@iupui.edu Please reference the child's complete name in the subject line. Additional information can also be sent to the physician's attention at:

IU Child Protection Program
c/o Riley Hospital
575 Riley Hospital Dr.
XE 040
Indianapolis, IN 46202

* To attach a document or photos please use the button below. Hold the control key to select multiple files.
* You can upload no more than 10240 KB (10 MB) of data at a time. The UITS attachment filters block the following file types:
.ade .adp .app .asp .bas .bat .chm .cmd .com .cpl .crt .csh .exe .fxp .hlp .hta .htr .inf .ins .isp .jar .js .jse .ksh .lnk .mda .mdb .mde .mdt .mdw .mdz
.mht .msc .msi .msp .mst .ops .pcd .pif .prf .prg .reg .scf .scr .sct .shb .shs .url .vb .vbe .vbs .wsc .wsf .wsh. The message contains a .zip file attachment that contains one or more of the blocked file extensions.
(Note: x-ray images on CD must come by mail-suggest overnight) Thank you for your referral. We look forward to working with you.
* Before you submit the form, you MUST PRINT the document if you need to keep a copy of it for your files. You will receive an email confirmation that the submission was received, but it will not include the form itself.