Alphabest Child Abuse Report Form
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1CHILD ABUSE
REPORT FORM
Please complete the following information for reporting Child Abuse:
Date of Report: __________________Date of incident: _____________________
Site Location:_______________________________________________________
Name of person making report: ________________________________________
Name of Child: _____________________________________________________
Address of Child’s Legal Guardian:_____________________________________
City, State, Zip:_____________________________________________________
Name of person suspected of the abuse or neglect:__________________________
Details of Incident: __________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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Name of Witnesses:
Phone Number:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Agency Name given report:_______________________Phone: _______________
Name of Contact/Investigator:__________________________________________
Outcome of Call: ____________________________________________________
Follow up needed: ___________________________________________________
Employee Signature:_____________________________ Date:______________
Manager Signature:______________________________ Date:______________
A copy of this report should be retained for our records.
Revised 6-1-2015
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Parent category: Legal