Suspected Child Abuse Report Form (Page 2 of 2) in pdf

DEFINITIONS AND GENERAL INSTRUCTIONS FOR COMPLETION OF FORM SS 8572

All Penal Code (PC) references are located in Article 2.5 of the PC. This article is known as the Child Abuse and Neglect Reporting

Act (CANRA). The provisions of CANRA may be viewed at: (specify “Penal Code” and search

for Sections 11164-11174.3). A mandated reporter must complete and submit the form SS 8572 even if some of the requested

information is not known. (PC Section 11167(a).)

MANDATED CHILD ABUSE REPORTERS

IV. INSTRUCTIONS (Continued)



Mandated child abuse reporters include all those individuals

SECTION B – REPORT NOTIFICATION: Complete the

and entities listed in PC Section 11165.7.

name and address of the designated agency notified, the

date/time of the phone call, and the name, title, and telephone

number of the official contacted.

II. TO WHOM REPORTS ARE TO BE MADE

(“DESIGNATED AGENCIES”)



SECTION C – VICTIM (One Report per Victim): Enter



Reports of suspected child abuse or neglect shall be made by

the victim’s name, address, telephone number, birth date or

mandated reporters to any police department or sheriff’s

approximate age, sex, ethnicity, present location, and, where

department (not including a school district police or security

applicable, enter the school, class (indicate the teacher’s

department), the county probation department (if designated

name or room number), and grade. List the primary language

by the county to receive mandated reports), or the county

spoken in the victim’s home. Check the appropriate yes-no

welfare department. (PC Section 1165.9.)

box to indicate whether the victim may have a developmental

disability or physical disability and specify any other

III. REPORTING RESPONSIBILITIES

apparent disability. Check the appropriate yes-no box to

indicate whether the victim is in foster care, and check the



Any mandated reporter who has knowledge of or observes a

appropriate box to indicate the type of care if the victim was

child, in his or her professional capacity or within the scope

in out-of-home care. Check the appropriate box to indicate

of his or her employment, whom he or she knows or

the type of abuse. List the victim’s relationship to the

reasonably suspects has been the victim of child abuse or

suspect. Check the appropriate yes-no box to indicate

neglect shall report such suspected incident of abuse or

whether photos of the injuries were taken. Check the

neglect to a designated agency immediately or as soon as

appropriate box to indicate whether the incident resulted in

practically possible by telephone and shall prepare and send a

the victim’s death.

written report thereof within 36 hours of receiving the



information concerning the incident. (PC Section 11166(a).)

SECTION D – INVOLVED PARTIES: Enter the

requested information for: Victim’s Siblings, Victim’s



No mandated reporter who reports a suspected incident of

Parents/Guardians, and Suspect. Attach extra sheet(s) if

child abuse or neglect shall be held civilly or criminally liable

needed (provide the requested information for each individual

for any report required or authorized by CANRA. Any other

on the attached sheet(s)).

person reporting a known or suspected incident of child abuse



or neglect shall not incur civil or criminal liability as a result

SECTION E – INCIDENT INFORMATION: If multiple

of any report authorized by CANRA unless it can be proven

victims, indicate the number and submit a form for each

the report was false and the person knew it was false or made

victim. Enter date/time and place of the incident. Provide a

the report with reckless disregard of its truth or falsity. (PC

narrative of the incident. Attach extra sheet(s) if needed.

Section 11172(a).)

V. DISTRIBUTION

IV. INSTRUCTIONS



Reporting Party: After completing Form SS 8572, retain



SECTION A – REPORTING PARTY: Enter the

the yellow copy for your records and submit the top three

mandated reporter’s name, title, category (from PC Section

copies to the designated agency.

11165.7), business/agency name and address, daytime



telephone number, and today’s date. Check yes-no whether

Designated Agency: Within 36 hours of receipt of Form SS

the mandated reporter witnessed the incident. The signature

8572, send white copy to police or sheriff’s department, blue

area is for either the mandated reporter or, if the report is

copy to county welfare or probation department, and green

telephoned in by the mandated reporter, the person taking the

copy to district attorney’s office.

telephoned report.

ETHNICITY CODES

1 Alaskan Native

6 Caribbean

11 Guamanian

16 Korean

22 Polynesian

27 White-Armenian

2 American Indian

7 Central American

12 Hawaiian

17 Laotian

23 Samoan

28 White-Central American

3 Asian Indian

8 Chinese

13 Hispanic

18 Mexican

24 South American

29 White-European

4 Black

9 Ethopian

14 Hmong

19 Other Asian

25 Vietnamese

30 White-Middle Eastern

5 Cambodian

10 Filipino

15 Japanese

21 Other Pacific Islander

26 White

31 White-Romanian

Suspected Child Abuse Report Form Page 2

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