CSUCE Suspected Child Abuse and Neglect Report Form
Instructions: Fill this form out promptly and as completely as possible. Submit as recommended below.
Legal name of youth: Address: Parent(s) or Guardian: Parent’s Address (if different): City: Parent’s Place of Employment: Family Composition: 1. Check items that apply: dislocation/sprains twisting/shaking malnutrition exposure to elements Description:
Birth date: City:
Sex: Grade:
Home Phone: Work Phone:
lack of supervision abandonment burns, scald medical neglect
emotional neglect educational neglect physical neglect
2. Briefly describe the reporter’s concern for the youth: 3. Describe the youth’s account of how the incident occurred and name possible witnesses: 4. Describe any previously known or suspected abuse or neglect to youth or siblings: 5. Provide name(s), address(es) and relationship of youth to person(s) responsible for suspected abuse or neglect (if known): 6. Call to Social Services Name of person reporting: county:
Recommendations: Print reporting forms in triplicate. Send original to your local social service agency and use the others for Colorado State University Cooperative Extension files.
date:
time:
person taking report: position: