Child Abuse Or Neglect Reporting Form - Confidential

Confidential

Child Abuse or Neglect Reporting Form

 

 

Place in School Principal’s Child Abuse or Neglect File

 

 

 

REPORTING   P ARTY  

 

Name   _ ________________________   T itle   _ ____________________   D ate   o f   R eport   _ ________________  

Address   _ ________________________________________________   T elephone   _ ___________________  

 

 

 

 

 

 

 

 

__________________________________________  

 

 

 

 

 

 

 

Signature   o f   R eporting   P arty  

REPORT   S ENT   T O  

 

Police  

Department   D ivision   o f   C hild   a nd   F amily   S ervices             D ate     _ __________   T ime   _ ______  

C  

 

Agency   N ame   _ ___________________________     O fficial   C ontacted   _ _____________________________  

Agency   A ddress   _ _________________________________________   T elephone   _ ____________________  

Case   n umber   _ _____________________________  

 

PARTIES   I NVOLVED  

Victim  

Name   _ _________________________________     B irth   D ate   _ _______________                         M ale                         F emale  

Address   _ _______________________________________________     T elephone     _ ___________________  

Primary   L anguage   _ ___________________________     R ace     _ ____________________________________  

 

Siblings   ( include   n ame,   b irth   d ate,   g ender,   a nd   r ace,   i f   a vailable)  

1.     _ ___________________________________         4 .     _ __________________________________________  

2.     _ ___________________________________         5 .     _ __________________________________________  

3.     _ ___________________________________         6 .     _ __________________________________________  

 

Parents/Legal   G uardians  

Name     _ ________________________________           A ddress     _ ___________________________________  

Telephone   _ ___________________     P rimary   L anguage     _ _______________     R ace     _ ________________  

 

INCIDENT   I NFORMATION  

Check   b ox   i f   e xtra   s heets   o r   o ther   i nformation   i s   a ttached  

 

Date/Time   o f   I ncident     _ __________________________     P lace   o f   I ncident     _ ______________________  

Type   o f   A buse   S uspected   ( Check   a ll   t hat   a re   r elevant)  

Physical                               Sexual                      

Emotional                        

Physical   N eglect                                 Educational   N eglect  

 

Overview   o f   r eproted   a buse   o r   n eglect:    

 

 

Summarize   w hat   t he   a bused   o r   n eglected   c hild   o r   p erson   a ccompanying   t he   c hild   s aid   h appened:  

 

 

Explain   k nown   h istory   o f   s imilar   i ncidents   f or   t his   c hild: