STATE OF CALIFORNIA - HEALTH AHD HUMAN SERVICES AGENCY
CHILDREN AND FAMILY SERVICES DIVISION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
OUTCOMES AND ACCOUNTABILITY BUREAU
SOCIAL WORKER DISCLOSURE REPORT
Today’s Date:
Date of Incident:
Report ID Number:
REPORTER INFORMATION
Last Name:
First:
Position:
Reporter Contact Information:
Phone Number:
May we contact you to follow up on
Do you consent to disclosure of
report?
your identity?
I
I
I
I
Yes
No
Yes
No
INCIDENT AND AGENCY INFORMATION
County:
Agency Name:
Phone Number:
Agency Address:
Type of Concern
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Endangers the Health or Well-being of a child
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Contrary to statute/regulation
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Contrary to Public Policy
Describe the child welfare policy, procedure, or practice you are concerned about:
Is this concern related to a specific case?
If yes, provide name or child identifying information:
Case or Referral ID (CWS):
I
I
Yes
No
Case Open?
Type of Case:
Child’s Location:
☐
☐
☐
☐
☐
☐
☐
ER
FM
FR
PP
ST
Yes
No
If yes, provide additional information:
Is there immediate child safety involved?
☐
☐
Yes
No
Contact Information:
Have you reported this concern to the agency?
If yes, list the parties notified:
I
I
Yes
No
Was any action taken?
If so, describe action taken:
I
I
Yes
No
ACKNOWLEDGEMENT
The above information is true to the best of my knowledge. I understand that unless I consent to disclosure, my identity will not be disclosed by the
California Department of Social Services pursuant to Welfare & Institutions Code Section 10605.5 (a) (2) unless there is an immediate health and
safety risk to a child.
SOC 886 (12/15)