suspectedchildabusereport-FresnoCounty.doc

SUSPECTED CHILD ABUSE REPORT To Be Completed by Mandated Child Abuse Reporters Pursuant to Penal Code Section 11166 PLEASE PRINT OR TYPE case name: case number: a. reportingparty NAME OF MANDATED REPORTER TITLE MANDATED REPORTER CATEGORY REPORTERS BUSINESS/AGENCY NAME AND ADDRESS Street City Zip DID MANDATED REPORTER WITNESS THE INCIDENT? YES NO REPORTERS TELEPHONE (DAYTIME) (?????) ????? SIGNATURE TODAYS DATE b. reportnotification LAW ENFORCEMENT COUNTY PROBATION COUNTY WELFARE / CPS (Child Protective Services) AGENCY ADDRESS Street City Zip DATE/TIME OF PHONE CALL OFFICIAL CONTACTED – TITLE TELEPHONE () victim one report per victim NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX AGE SEX ETHNICITY ADDRESS Street City Zip TELEPHONE (?????) PRESENT LOCATION OF VICTIM SCHOOL CLASS GRADE PHYSICALLY DISABLED? YES NO DEVELOPMENTALLY DISABLED YES NO OTHER DISABILITY (SPECIFY) PRIMARY LANGUAGE SPOKEN IN HOME IN FOSTER CARE? YES NO IF VICTIM WAS IN OUT-OF-HOME CARE AT TIME OF INCIDENT, CHECK TYPE OF CARE: DAY CARE CHILD CARE CENTER FOSTER FAMILY HOME FAMILY FRIEND GROUP HOME OR INSTITUTION RELATIVES HOME TYPE OF ABUSE (CHECK ONE OR MORE) PHYSICAL MENTAL SEXUAL NEGLECT OTHER (SPECIFY) RELATIONSHIP TO SUSPECT PHOTOS TAKEN? YES NO DID THE INCIDENT RESULT IN THIS VICTIMS DEATH? YES NO UNK victims siblings name birth