Suspected Child Abuse Mandated Reporter Incident Form

Documents a mandated reporter's observations, disclosures, and notifications to child protective services and law enforcement when child abuse or neglect is suspected. Supports legal compliance and creates an audit trail of the report.

Important Notice to Reporter

• Mandated Reporter Legal Notice
  This form documents your internal report. It does NOT replace your legal duty to report directly to Child Protective Services (CPS) or law enforcement. Mandated reporters are required by law to report suspected abuse or neglect immediately upon reasonable suspicion — you do not need proof. Failure to report may result in criminal liability. All information collected here is confidential and used solely for child protection and compliance purposes.
• I confirm I have already contacted or am in the process of contacting CPS or law enforcement directly, as required by law.

Reporter Information

• Reporter Full Name
• Job Title / Role
• Department / Program
• Reporter Phone Number
• Reporter Email Address
• Date This Form Is Being Completed
• Time This Form Is Being Completed

Child / Victim Information

• Child's Full Name
• Child's Date of Birth
• Child's Age (if date of birth unknown)
• Child's Gender (as known or reported)
• Child's Grade Level or Program
• Child's Home Address (if known)
• Parent / Guardian Name(s)
• Parent / Guardian Phone Number

Nature of Suspected Abuse or Neglect

• Type of Suspected Abuse or Neglect (select all that apply)
• If 'Other / Unknown', please describe
• Basis for Suspicion (select all that apply)

Observations and Disclosure Details

• Date Abuse / Neglect Was Observed or Disclosed
• Approximate Time of Observation or Disclosure
• Location Where Observation or Disclosure Occurred
• Physical Observations (describe injuries, marks, or physical condition observed)
• Child's Exact Words (verbatim disclosure, if applicable)
• Behavioral Observations
• Questions Asked by Reporter (if any)
• Photographic Evidence (if safely obtained and permitted by policy)

Suspected Perpetrator Information

• Is the suspected perpetrator known?
• Suspected Perpetrator Name (if known)
• Relationship to Child
• Perpetrator Address (if known)
• Physical Description of Suspected Perpetrator (if identity unknown)

Authorities Notified

• Was a report made to Child Protective Services (CPS)?
• CPS Agency Name
• Date CPS Was Contacted
• Time CPS Was Contacted
• CPS Worker / Intake Specialist Name (if provided)
• CPS Report Confirmation / Reference Number
• Was a report made to law enforcement?
• Law Enforcement Agency Name
• Date Law Enforcement Was Contacted
• Officer / Detective Name (if provided)
• Law Enforcement Case / Report Number
• If neither CPS nor law enforcement was contacted, explain why

Internal Notifications and Follow-Up

• Was your supervisor or designated administrator notified?
• Supervisor / Administrator Name Notified
• Date Supervisor Was Notified
• Immediate Safety Actions Taken
• Describe other immediate safety actions taken
• Additional Notes or Context
• Supporting Documents (attach any written notes, drawings, or related records)

Reporter Certification

• Certification
  I certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand that this internal record does not substitute for my legal obligation to report directly to CPS or law enforcement. I understand that this report is confidential and that retaliation against a mandated reporter acting in good faith is prohibited by law.
• Reporter Signature
• Date of Signature