Fillable Printable Child Abuse Report Sample Form
Fillable Printable Child Abuse Report Sample Form
Child Abuse Report Sample Form
NAME OF MANDATED REPORTER TITLE MANDATED REPORTER CATEGORY
REPORTER'S BUSINESS/AGENCY NAME AND ADDRESS Street City Zip DID MANDATED REPORTER WITNESS THE INCIDENT?
❒ YES ❒ NO
REPORTER'S TELEPHONE (DAYTIME) SIGNATURE TODAY'S DATE
( )
❒ LAW ENFORCEMENT ❒ COUNTY PROBATION AGENCY
❒ COUNTY WELFARE / CPS (Child Protective Services)
ADDRESS Street City Zip DATE/TIME OF PHONE CALL
OFFICIAL CONTACTED - TITLE TELEPHONE
( )
NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY
ADDRESS Street City Zip TELEPHONE
( )
PRESENT LOCATION OF VICTIM SCHOOL CLASS GRADE
PHYSICALLY DISABLED? DEVELOPMENTALLY DISABLED? OTHER DISABILITY (SPECIFY) PRIMARY LANGUAGE
❘❒ YES ❒ NO ❒ YES ❒ NO SPOKEN IN HOME
IN FOSTER CARE? IF VICTIM WAS IN OUT-OF-HOME CARE AT TIME OF INCIDENT, CHECK TYPE OF CARE: TYPE OF ABUSE (CHECK ONE OR MORE)
❒ YES ❒ DAY CARE ❒ CHILD CARE CENTER ❒ FOSTER FAMILY HOME ❒ FAMILY FRIEND ❒ PHYSICAL ❒ MENTAL ❒ SEXUAL ❒ NEGLECT
❒ NO ❒ GROUP HOME OR INSTITUTION ❒ RELATIVE'S HOME ❒ OTHER (SPECIFY)
RELATIONSHIP TO SUSPECT PHOTOS TAKEN? DID THE INCIDENT RESULT IN THIS
❒ YES ❒ NO VICTIM'S DEATH? ❒ YES ❒ NO ❒ UNK
NAME BIRTHDATE SEX ETHNICITY NAME BIRTHDATE SEX ETHNICITY
1. 3.
2. 4.
NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY
ADDRESS Street City Zip HOME PHONE BUSINESS PHONE
( ) ( )
NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY
ADDRESS Street City Zip HOME PHONE BUSINESS PHONE
( ) ( )
SUSPECT'S NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY
ADDRESS Street City Zip TELEPHONE
( )
OTHER RELEVANT INFORMATION
IF NECESSARY, ATTACH EXTRA SHEET(S) OR OTHER FORM(S) AND CHECK THIS BOX IF MULTIPLE VICTIMS, INDICATE NUMBER:
DATE / TIME OF INCIDENT PLACE OF INCIDENT
NARRATIVE DESCRIPTION (What victim(s) said/what the mandated reporter observed/what person accompanying the victim(s) said/similar or past incidents involving the victim(s) or suspect)
A.
REPORTING
PARTY
❒
D. INVOLVED PARTIES
VICTIM'S
SIBLINGS
SUSPECTED CHILD ABUSE REPORT
DEFINITIONS AND INSTRUCTIONS ON REVERSE
DO NOT submit a copy of this form to the Department of Justice (DOJ). The investigating agency is required under Penal Code Section 11169 to submit to DOJ a
Child Abuse Investigation Report Form SS 8583 if (1) an active investigation was conducted and (2) the incident was determined not to be unfounded.
WHITE COPY-Police or Sheriff's Department; BLUE COPY-County Welfare or Probation Department; GREEN COPY- District Attorney's Office; YELLOW COPY-Reporting Party
SS 8572 (Rev. 12/02)
B. REPORT
NOTIFICATION
E. INCIDENT INFORMATION
SUSPECT
VICTIM'S
PARENTS/GUARDIANS
CASE NAME:
CASE NUMBER:
To Be Completed by Mandated Child Abuse Reporters
Pursuant to Penal Code Section 11166
PLEASE PRINT OR TYPE
C. VICTIM
One report per victim
