Alaska Centralized Report







In this section, you will fill out your contact information so that we can contact
            you if we need additional information.  For mandated reporters, we must have at least your name and a phone
            number to ensure that we can properly address your concern in case additional information is needed. If you choose to remain anonymous, please enter unknown in the first and last name fields and type in (000)000-0000 as the phone number since those fields are required. An anonymous Report of Harm can also be made by calling 1-800-478-9996. In this section, you will fill out your contact information so that we can contact you if we need additional information. For mandated reporters, we must have at least your name and a phone number to ensure that we can properly address your concern in case additional information is needed. If you choose to remain anonymous, please enter unknown in the first and last name fields and type in (000)000-0000 as the phone number since those fields are required. An anonymous Report of Harm can also be made by calling 1-800-478-9996.
Date of Birth

In this section, you will describe what caused you to fill out a report on the involved
            person.  If anyone saw the incident happen, you will need to add their contact information
            to the Other Participant Section.  Please answer as many of the following questions as you can. In this section, you will describe what caused you to fill out a report on the involved person. If anyone saw the incident happen, you will need to add their contact information to the Other Participant Section. Please answer as many of the following questions as you can.
Incident Date
:
Result of Incident



Sending Additional Documentation Via

Please describe the incident in details and include the following information. Please describe the incident in details and include the following information.















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