Exhibit 5-1
Sample Information to Obtain from Reporter During Intake
Demographic Information


  • Name
  • Age (date of birth)
  • Sex
  • Race
  • Permanent address
  • Current location
  • School or daycare attending

Parents or Caregivers:*

  • Name
  • Age (date of birth)
  • Race
  • Relationship to the child
  • Permanent address
  • Current location
  • Place of employment
  • Telephone number(s)

* If the person alleged to have maltreated the child is a caregiver other than the child's parents, the above information should be gathered about both the parents and caregiver. back

Family Composition:

  • Names
  • Ages (dates of birth)
  • Sex
  • Race
  • Location of all children in the family
  • Names, ages, and location(s) of other children in the alleged maltreater's care
  • Names of other relatives and nonrelatives living in the home, if the maltreater is not the birth parent (e.g., a babysitter, boyfriend, stepparent)
  • Names, addresses, and telephone numbers of other relatives and their relationship to the child
  • Names, addresses, telephone numbers, and other sources of information about the family


  • Name
  • Address
  • Telephone number
  • Relationship to the child or family
  • How they learned of alleged maltreatment

Information Regarding the Alleged Maltreatment


Nature of Maltreatment:
(Specific characteristics and parental acts or omissions)

  • Physical abuse: burning, beating, kicking, biting, and other physical abuse
  • Neglect: abandonment, withholding of needed medical care, lack of supervision, lack of adequate food or shelter, emotional deprivation, failure to register or send to school, and the effects of exposure to partner abuse
  • Sexual abuse or exploitation: fondling, masturbation, oral or anal sex, sexual intercourse, viewing or involved in pornography or forced prostitution
  • Emotional maltreatment: constant berating or rejecting treatment, scapegoating, and bizarre/cruel/ritualistic forms of punishment


  • Extent of the physical injury (e.g., second- and third-degree burns on half of the child's body)
  • Location of the injury on the child's body
  • Extent of the emotional injury to the child (e.g., suicidal behavior, excessive fear of the parents or caregivers)


  • Prior incidents of abuse or neglect
  • How long the abuse or neglect has been occurring
  • Whether abuse or neglect has increased in frequency or remained relatively constant


  • Setting where abuse or neglect occurred (e.g., home, school, supermarket)

Examples of Information Regarding the Parents or Caregivers

Emotional and Physical Condition:

  • Expresses feelings in positive and healthy ways
  • Misuses drugs or alcohol
  • Suffers from physical illness
  • Suffers from mental illness


  • Good impulse control
  • Awareness of triggers that cause them to be angry
  • Engagement in violent outbursts
  • Engagement in bizarre or irrational behavior
  • Possession of weapons in the home
  • Abuse of pets

View of the Child:

  • Empathizes with the child
  • Views the child as bad or evil
  • Blames the child for the child's condition

Relationships Outside the Home:

  • Friends and the quality of those friendships
  • Social and emotional isolation

Child-rearing Practices:

  • Realistic and age-appropriate expectations of the child
  • Extent to which use of inappropriate verbal or physical punishment as the first response to misbehavior
  • Knowledge of different disciplinary techniques appropriate for the child's age and developmental status

Examples of Information Regarding the Child

Child's Condition:

  • Physical condition
  • Emotional condition
  • Disabilities or impairments
  • Strengths

Child's Behavior:

  • Extremes in behavior
  • Appropriateness of behavior given child's age and developmental level

Examples of Information Regarding the Family

Family Characteristics:

  • Single parent or blended family
  • Adequate family income
  • Parents employed
  • Flow of strangers in and out of home
  • Evidence of drug dealing in the home

Family Dynamics:

  • Serious marital conflict
  • Partner abuse
  • Disorganization and chaos

Family Supports:

  • Extended family members who are accessible and available
  • Relationships with others outside the family
  • Connections in the community, such as houses of worship