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The Role of Professional Child Care Providers in Preventing and Responding to Child Abuse and Neglect
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Author(s):
Children's Bureau
Karageorge, Kathy, Kendall, Rosemary |
| Year Published: 2008 |
Appendix E: Sample Report of Suspected Child Abuse and Neglect
Call: Local Social Services Agency or Law Enforcement Agency (Phone Numbers)
Date of Call(s):_________________________ Name of Person(s) Talked To:____________________
Notified: Designee (Center Director or Nurse)
Date of Notification:________________________ Date of This Report:__________________________
School: (School Name, Address, City, State, ZIP, Telephone Number)
| _______________________ Child's Last Name (legal) |
______________ First Name |
______ M. Init. |
____ M/F |
____ Age |
________ Birth date |
| _______________ Address |
____________ City |
_________ State |
____________ Zip Code |
_____________ Telephone |
Name of Person(s) Responsible for Child's Care: (Parents/Stepparents/Guardians/Custodial Parents)
| _______________ Address |
____________ City |
_________ State |
____________ Zip Code |
_____________ Telephone |
With Whom Does the Child Live:_____________________ Relationship:_________________________
| _______________ Address |
____________ City |
_________ State |
____________ Zip Code |
_____________ Telephone |
Person(s) Suspected of Abuse or Neglect: ___________________ Relationship:_________________
| _______________ Address |
____________ City |
_________ State |
____________ Zip Code |
_____________ Telephone |
Check appropriate space indicating type of suspected abuse being reported:
| ( ) Physical Injury | ( ) Sexual Abuse | ( ) Emotional Neglect/Abuse |
| ( ) Physical Neglect | ( ) Other (specify):______________________________________ | |
State the nature and extent of the current injury, neglect, or sexual abuse to the child in question and circumstances leading to the suspicion that the child is a victim of abuse or neglect:
Information concerning previous injury, sexual abuse or neglect experienced by this child or other children in this family situation, including previous action taken, if any:
State other information that may be helpful in establishing the cause of the child' status:
_______________________________________________________________________________________
| _________________________________________________________________ Signature and Title of Person Making Report |
_________ Date |
Distribution: Local Social Services or Law Enforcement Agency/Designee/Other
This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway.