Suspected Child Abuse Report Form

Information About the Incident

Date of Occurrence
(mm/dd/yyyy)

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Time of Occurrence
(Include whether a.m. or p.m.)

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Type of Abuse:
(Check all that apply)

Physical

Mental/Emotional

Sexual

Neglect

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Describe the incident in detail

(Be as specific and detailed as possible to the best of your recollection.)

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Information About the Victim(s)

List name(s) of victims if known and/or physical description(s):

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Age of Victim(s):

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Information About the Abuser

List name(s) of abuser if known and/or physical description(s):

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Information About Additional Witnesses

Were there any witnesses to the situation or treatment you have described other than yourself?

Yes

No

Don't Know

Name(s):

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Relationship:

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Contact Information:

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Who Have You Shared This Experience With So Far?

Have you spoken to anyone about your concerns?

Yes

No

Name(s):

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Relationship:

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Date of Contact:

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Optional Information About You
(The person filing this report)

Your Name:

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Address:

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Home Phone:

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Work Phone:

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E-Mail:

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Preferred Method of Contact:

Mobile Phone

Home Phone

Work Phone

E-mail

University Affiliation:

Undergraduate Student

Graduate Student

Faculty

Staff

Vendor

Visitor

Department/School:
(If applicable)

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