Appendix F
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 (Principal or School Social Worker)                                                                  

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






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