Report of Suspected Incident of Child Abuse 1. Name of worker (paid or volunteer) observing or receiving disclosure of child abuse: _____________ _____________________________________________________________________________________ 2. Child/Victim’s name: _______________________________________________________________ 3. Initial observation of, or conversation with, child/victim: Date _______________________________ _____________________________________________________________________________________ 4. Your observations (give detailed summary here): __________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 5. Child/Victim’s statement if possible (give a detailed summary here): _________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 6. Name of person suspected of abusing the child: __________________________________________ Relationship to the child/victim (paid staff, volunteer, family member, other): ______________________ 7. Reported to Clergy/Leadership: Date: ______________________________ Time: _______________ Comments: ___________________________________________________________________________ 8. Call to ChildLine: Date: ________________________________________ Time: ________________ Call to local children and youth agency: Date: _________________________ Time: ________________ Spoke with: _______________________________________ Comments/Summary: ________________ ____________________________________________________________________________________ 9. Call to child/victim’s parents: Date: ______________________________ Time: ________________ Spoke with: ________________________________________Comments/Summary: _______________ ____________________________________________________________________________________ 10. Other contacts: Date: _______________________________________ Time: __________________ Name: _____________________________________________Comments/Summary: _______________ _____________________________________________________________________________________
__________________________ __________________________ Signature of Reporter Date
This is a sample form. Please tailor this form to meet your congregation’s policy requirements.