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Items Needed
SUSPECTED CHILD ABUSE REPORT FORM
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Indicates required field
1. Date:
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2. Name of Person Filing Report:
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First
Last
3. Name of Child:
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First
Last
4. Child's Date of Birth:
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5. Child's Phone Number:
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6. Child's Address:
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Line 1
Line 2
City
State
Zip Code
Country
7. Parent/Guardian of Child:
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First
Last
8. Names & Ages of Other Children Residing in the Home:
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9. Nature of Suspected Abuse:
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Physical
Sexual
Emotional
Neglect
10. Why you believe the child is at risk:
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11. Any statements or disclosures made by the child:
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12. Information about the family, parents and alleged offender:
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13. Information about siblings or other children who may be at risk:
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14. Previous incidents or concerns about the child:
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15. Are there any immediate concerns about the child’s safety? If so, what are they?
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16. Information about other persons who may be witnesses or may have information about the child:
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17. Information about other persons or agencies closely involved with the child and/or family:
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18. Action taken: (including date and time):
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19. Name of youth's social worker:
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First
Last
20. Phone number of youth's social worker:
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21. Ministry’s Response:
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22. Follow up action:
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I agree that the above information will serve as a guide and will be necessary if a formal report is filed with the police or appropriate government agency. All information received is to be kept strictly confidential.
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First
Last
Please type your name as your digital signature.
Supervisor's Signature:
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First
Last
Submit