Fillable Printable Child Abuse Report Sample Form
Fillable Printable Child Abuse Report Sample Form
Child Abuse Report Sample Form
NAME OF MANDATED REPORTERTITLEMANDATED REPORTER CATEGORY
REPORTER'S BUSINESS/AGENCY NAME AND ADDRESSStreetCity ZipDID MANDATED REPORTER WITNESS THE INCIDENT?
❒ YES ❒ NO
REPORTER'S TELEPHONE (DAYTIME)SIGNATURETODAY'S DATE
( )
❒ LAW ENFORCEMENT ❒ COUNTY PROBATIONAGENCY
❒ COUNTY WELFARE / CPS (Child Protective Services)
ADDRESSStreetCityZipDATE/TIME OF PHONE CALL
OFFICIAL CONTACTED - TITLETELEPHONE
( )
NAME (LAST, FIRST, MIDDLE)BIRTHDATE OR APPROX. AGESEXETHNICITY
ADDRESSStreetCityZipTELEPHONE
( )
PRESENT LOCATION OF VICTIM SCHOOLCLASS GRADE
PHYSICALLY DISABLED? DEVELOPMENTALLY DISABLED? OTHER DISABILITY (SPECIFY)PRIMARY LANGUAGE
❘❒ YES ❒ NO❒ YES ❒ NOSPOKEN 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 ❒ NOVICTIM'S DEATH? ❒ YES ❒ NO ❒ UNK
NAMEBIRTHDATESEX ETHNICITYNAMEBIRTHDATESEX ETHNICITY
1.3.
2.4.
NAME (LAST, FIRST, MIDDLE)BIRTHDATE OR APPROX. AGESEXETHNICITY
ADDRESSStreetCityZipHOME PHONEBUSINESS PHONE
( )( )
NAME (LAST, FIRST, MIDDLE)BIRTHDATE OR APPROX. AGESEXETHNICITY
ADDRESSStreetCityZipHOME PHONEBUSINESS PHONE
( )( )
SUSPECT'S NAME (LAST, FIRST, MIDDLE)BIRTHDATE OR APPROX. AGESEXETHNICITY
ADDRESSStreetCityZipTELEPHONE
( )
OTHER RELEVANT INFORMATION
IF NECESSARY, ATTACH EXTRA SHEET(S) OR OTHER FORM(S) AND CHECK THIS BOXIF MULTIPLE VICTIMS, INDICATE NUMBER:
DATE / TIME OF INCIDENTPLACE 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
