Fillable Suspected Child Abuse Report Form (Page 2 of 2) in pdf

DEFINITIONS AND GENERAL INSTRUCTIONS FOR COMPLETION OF FORM SS 8572

All Penal Code (PC) references are located in Article 2.5 of the PC. This article is known as the Child Abuse and Neglect Reporting Act, also known as

CANRA. The Internet site is:

(specify Penal Code and search for Sections 11164-11174.3). A mandated

reporter must complete and submit the form SS 8572 even if some information is not known. (PC Section 11167(a).)

MANDATED CHILD ABUSE REPORTERS

IV. INSTRUCTIONS (Continued)

•

Mandated child abuse reporters include all those

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SECTION B - REPORT NOTIFICATION: Complete

individuals and entities as defined in PC Section 11165.7.

the name and address of the designated agency notified,

date of the written report, date/time of the phone call and

II. TO WHOM REPORTS ARE TO BE MADE

the name, title and telephone number of the official

(DESIGNATED AGENCIES)

contacted.

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Reports of suspected child abuse or neglect shall be made

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SECTION C - VICTIM (One Report per Family, siblings

by mandated reporters to any police department or sheriff’s

must have same parents/guardians): Enter the victim’s

department (not including a school district police or

name, address, telephone number, birth date or approximate

security department), county probation department (if

age, sex, ethnicity, present location, and where applicable

designated by the county to receive mandated reports) or

enter the school, class (indicate the teacher’s name or room

the county welfare department. (PC Section 11165.9.)

number), and grade. List the primary language spoken in

the victim’s home. Check the appropriate yes-no box for:

III. REPORTING RESPONSIBILITIES

developmentally disabled?, physically disabled? and specify

the victim’s other disability. To determine if the victim has

Any mandated reporter who has knowledge of or observes

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a disability, ask the victim’s parent or care giver. Also

a child, in his or her professional capacity or within the

check the appropriate yes-no box for in foster care?, indicate

scope of his or her employment, whom he or she knows or

type of care if the victim was in out-of-home care, indicate

reasonably suspects has been the victim of child abuse or

the type of abuse. List the victim’s relationship to the

neglect shall report such suspected instance of abuse or

suspect, check the appropriate yes-no box for photos

neglect to a designated agency immediately or as soon as

taken?, indicate whether the incident resulted in this

practically possible by telephone and shall prepare and send

victim’s death.

a written report thereof within 36 hours of receiving the

information concerning the incident. (PC Section

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SECTION D - INVOLVED PARTIES: Enter the

11166(a).)

requested information for: Victim’s Siblings, Victim’s

Parents/Guardians and the Suspect.

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No mandated reporter who reports a suspected instance of

child abuse or neglect shall be held civilly or criminally

SECTION E - INCIDENT INFORMATION: If multiple

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liable for any report required or authorized by the CANRA.

victims, enter the number. Enter date/time and place of the

Any other person reporting a known or suspected instance

incident. Provide a narrative of the incident. Attach extra

of child abuse or neglect shall not incur civil or criminal

sheets if needed.

liability as a result of any report authorized by the CANRA

unless it can be proven the report was false and the person

DISTRIBUTION

knew it was false or make the report with reckless

disregard of its truth or falsity. (PC Section 11172(a).)

Reporting Party: After completing Form SS 8572, retain

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the yellow copy for your records and submit the top three

IV. INSTRUCTIONS

copies to the designated agency.

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SECTION A - REPORTING PARTY: Enter the

Designated Agency: Within 36 hours of receipt of Form

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mandated reporter’s name, title, category (from PC Section

SS 8572, send white copy to police or sheriff, blue copy to

11165.7), business (agency) name and address, telephone

county welfare or probation, and green copy to district

number, a signature and today’s date. Also check yes-no

attorney.

whether you (the mandated reporter) witnessed the

incident. The signature area is for either the mandated

report or the person taking as telephoned report.

ETHNICITY CODES

1 Alaskan Native

6 Caribbean

11 Guamanian

16 Korean

22 Polynesian

27 White-Armenian

2 American Indian

7 Central American

12 Hawaiian

17 Laotian

23 Samoan

28 White-Central American

3 Asian Indian

8 Chinese

13 Hispanic

18 Mexican

24 South American

29 White-European

4 Black

9 Ethiopian

14 Hmong

19 Other Asian

25 Vietnamese

30 White-Middle Eastern

5 Cambodian

10 Filipino

15 Japanese

21 Other Pac Islndr

26 White

31 White-Romanian

Suspected Child Abuse Report Form Page 2

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