Suspected Child Abuse Report

Suspected Child Abuse Report - Print SUSPECTED CHILD ABUSE...

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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
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