Looking for a Suspected Child Abuse Report Form Templates? Download it for free!

LIBRARY MANDATED REPORT OF SUSPECTED CHILD ABUSE FORM

To be completed by:

The person who has reasonable cause to suspect that a child is a victim of child abuse

and the administrator to whom it was reported

THIS DOCUMENTATION MUST BE MAINTAINED IN SEPARATE AND CONFIDENTIAL FILE

NAME __________________________________________________________ Initials ______________

DEPARTMENT __________________________________ LIBRARY ____________________________

Administrator to whom reported ______________________________Initials____ Date & time _________

CHILD’S NAME ________________________________________________________________________

Date and time information was received or observation made of disclosure of suspected child abuse.

_______________________________________________________________________________________

If this report was made because of child’s disclosure to you what was the child’s statement/response (exact

quotes if possible)

_______________________________________________________________________________________

If this report was made because of your observation, describe your observations as specifically as possible.

_______________________________________________________________________________________

If this report was made because of third party disclosure to you, what was the third party’s

statement/response (exact quotes if possible.)

_______________________________________________________________________________________

Observations of, or conversations with the child (i.e. date, place, observations, comments, questions asked,

etc,)

_______________________________________________________________________________________

Date and time ChildLine (1-800-932-0313) called _______________________________________________

Date and time of submission of Report of Suspected Child Abuse (CY-47) ___________________________

Mandate To Report Suspected Child Abuse Form - Employees Of Tredyffrin Township Libraries Page 4