name of mandated reporter title mandated reporter category reporter's business/agency name and address street city zip did mandated reporter witness t...
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Print SUSPECTED CHILD ABUSE REPORT To Be Completed by Mandated Child Abuse Reporters CASE NAME: Pursuant to Penal Code Section 11166
B. REPORT
A. REPORTING NOTIFICATION PARTY
PLEASE PRINT OR TYPE NAME OF MANDATED REPORTER
TITLE
REPORTER'S BUSINESS/AGENCY NAME AND ADDRESS
Street
CASE NUMBER: MANDATED REPORTER CATEGORY
City
(
SIGNATURE
❒ COUNTY PROBATION
AGENCY
❒ COUNTY WELFARE / CPS (Child Protective Services) ADDRESS
Street
City
Zip
OFFICIAL CONTACTED - TITLE
One report per victim
C. VICTIM
(
)
BIRTHDATE OR APPROX. AGE
Street
City
Zip
SCHOOL
PHYSICALLY DISABLED? DEVELOPMENTALLY DISABLED? ❘❒ YES ❒ NO
❒ YES ❒ NO
SEX
ETHNICITY
TELEPHONE
( PRESENT LOCATION OF VICTIM
)
CLASS
OTHER DISABILITY (SPECIFY)
GRADE
PRIMARY LANGUAGE 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
❒ PHYSICAL ❒ MENTAL ❒ SEXUAL ❒ NEGLECT
❒ NO
❒ GROUP HOME OR INSTITUTION
❒ CHILD CARE CENTER
❒ FOSTER FAMILY HOME
NAME
BIRTHDATE
❒ FAMILY FRIEND
❒ RELATIVE'S HOME
SEX
❒ OTHER (SPECIFY) PHOTOS TAKEN?
DID THE INCIDENT RESULT IN THIS
❒ YES
VICTIM'S DEATH?
❒ NO
ETHNICITY
NAME
1.
3.
2.
4.
NAME (LAST, FIRST, MIDDLE)
ADDRESS
Street
City
Zip
HOME PHONE
(
(
City
Zip
HOME PHONE
( ADDRESS
Street
ETHNICITY
SEX
ETHNICITY
SEX
ETHNICITY
SEX
ETHNICITY
BUSINESS PHONE
)
(
)
BIRTHDATE OR APPROX. AGE
City
❒ UNK
SEX
)
BIRTHDATE OR APPROX. AGE
Street
❒ NO
BUSINESS PHONE
)
NAME (LAST, FIRST, MIDDLE)
ADDRESS
❒ YES
BIRTHDATE
BIRTHDATE OR APPROX. AGE
SUSPECT'S NAME (LAST, FIRST, MIDDLE)
SUSPECT
DATE/TIME OF PHONE CALL
TELEPHONE
RELATIONSHIP TO SUSPECT
VICTIM'S SIBLINGS
❒ NO
)
❒ LAW ENFORCEMENT
ADDRESS
VICTIM'S PARENTS/GUARDIANS
DID MANDATED REPORTER WITNESS THE INCIDENT?
TODAY'S DATE
NAME (LAST, FIRST, MIDDLE)
D. INVOLVED PARTIES
Zip
❒ YES REPORTER'S TELEPHONE (DAYTIME)
Reset Form
Zip
TELEPHONE
(
)
E. INCIDENT INFORMATION
OTHER RELEVANT INFORMATION
IF NECESSARY, ATTACH EXTRA SHEET(S) OR OTHER FORM(S) AND CHECK THIS BOX DATE / TIME OF INCIDENT
❒
IF MULTIPLE VICTIMS, INDICATE NUMBER:
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)
SS 8572 (Rev. 12/02)
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
