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Home > The Role of Educators in Preventing and Responding to Child Abuse and Neglect > The Role of Educators in Preventing and Responding to Child Abuse and Neglect: Appendix F - Sample Report of Suspected Child Abuse and Neglect
The Role of Educators in Preventing and Responding to Child Abuse and Neglect
User Manual Series (2003)
Printable version | (PDF - 151 KB) Appendix F
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| _______________________ 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.
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