Suspected Child Abuse Report Form
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1
2SUSPECTED CHILD ABUSE REPORT
To Be Completed by Mandated Child Abuse Reporters
Pursuant to Penal Code Section 11166
CASE NAME:
PLEASE PRINT OR TYPE
CASE NUMBER:
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 SPOKEN IN HOME
YES
NO
YES
NO
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
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
c
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 SHEETS(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)
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.
cc: Police or Sheriff’s Department; County Welfare or Probation Department; District Attorney’s Office; Reporting Party
Department of Justice SS8572 (Rev. 12/02)
SUSPECTED CHILD ABUSE REPORT
CWS/CMS Case Management System
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