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Run: Suspected Child Abuse Mandated Reporter Incident Form

Record suspected child abuse or neglect observations, disclosures, and mandated notifications in one incident form. Use it to capture the facts, document who...

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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. (required)

Yes No N/A

Reporter Information

Reporter Full Name (required)

Job Title / Role (required)

Department / Program (required)

Reporter Phone Number (required)

Reporter Email Address (required)

Date This Form Is Being Completed (required)

Time This Form Is Being Completed (required)

Child / Victim Information

Child's Full Name (required)

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) (required)

If 'Other / Unknown', please describe

Basis for Suspicion (select all that apply) (required)

Observations and Disclosure Details

Date Abuse / Neglect Was Observed or Disclosed (required)

Approximate Time of Observation or Disclosure

Location Where Observation or Disclosure Occurred (required)

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? (required)

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)? (required)

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? (required)

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? (required)

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 (required)

Date of Signature (required)

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