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SUSPECTED CHILD ABUSE REPORT FORM
Indicates required field
2. Name of Person Filing Report:
3. Name of Child:
4. Child's Date of Birth:
5. Child's Phone Number:
6. Child's Address:
7. Parent/Guardian of Child:
8. Names & Ages of Other Children Residing in the Home:
9. Nature of Suspected Abuse:
10. Why you believe the child is at risk:
11. Any statements or disclosures made by the child:
12. Information about the family, parents and alleged offender:
13. Information about siblings or other children who may be at risk:
14. Previous incidents or concerns about the child:
15. Are there any immediate concerns about the child’s safety? If so, what are they?
16. Information about other persons who may be witnesses or may have information about the child:
17. Information about other persons or agencies closely involved with the child and/or family:
18. Action taken: (including date and time):
19. Name of youth's social worker:
20. Phone number of youth's social worker:
21. Ministry’s Response:
22. Follow up action:
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.
Please type your name as your digital signature.
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nner Hope Youth Ministries
PO Box 74084, RPO Hillcrest Park
Vancouver, BC V5V 5C8
Inner Hope Youth Ministries.
Registered Canadian Charity - 83500 4557 RR0001.