Cpi-2 - Written Report Form For Mandated Reporters Of Child Abuse/neglect Page 2
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1
2Suspected Child Victim’s Name
:
(from Page 1)
What is current circumstance/condition of the child victim and are they currently in danger of serious injury or
harm? Why?
Identity of any child or adult who gave any explanation of the child’s injury or condition, along with the date and
details of the explanation:
How and when did this child(ren) victim come to your attention?
What services and/or referrals have been provided to the child/family by you or your agency/facility?
Have you previously reported abuse/neglect on this child or any of his siblings?
No
Yes
If yes, please give number of times, approximate dates, persons reported, office to which reported and outcome,
if known:
What is going well for the family; areas of parenting they handle adequately; and, was there a time when they
adequately cared for or protected the child(ren), if known?
Other Pertinent Information
(other persons with information about the family and way to contact)
Reporter’s Printed Name:
Phone # to Contact:
Signature:
Date:
Best Contact Time:
Position/Type of Reporter:
Agency/Provider:
Reporter’s Address:
Page 2
DCF/CW Form CPI-2
Reissued: 01/12
Replacing: 6/08
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