NAME OF MANDATED REPORTER TITLE MANDATED REPORTER CATEGORY

NAME OF MANDATED REPORTER TITLE MANDATED REPORTER CATEGORY

REPORTER’S BUSINESS/AGENCY NAME AND ADDRESS Street City Zip DID MANDATED REPORTER WITNESS THE INCIDENT?

❒ YES ❒ NO

REPORTER’S TELEPHONE (DAYTIME) SIGNATURE TODAY’S DATE

( )

❒ LAW ENFORCEMENT ❒ COUNTY PROBATION AGENCY

❒ COUNTY WELFARE / CPS (Child Protective Services)

ADDRESS Street City Zip DATE/TIME OF PHONE CALL

OFFICIAL CONTACTED – TITLE TELEPHONE

( )

NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY

ADDRESS Street City Zip TELEPHONE

( )

PRESENT LOCATION OF VICTIM SCHOOL CLASS GRADE

PHYSICALLY DISABLED? DEVELOPMENTALLY DISABLED? OTHER DISABILITY (SPECIFY) PRIMARY LANGUAGE

❘❒ YES ❒ NO ❒ YES ❒ NO SPOKEN IN HOME

IN FOSTER CARE? IF VICTIM WAS IN OUT-OF-HOME CARE AT TIME OF INCIDENT, CHECK TYPE OF CARE: TYPE OF ABUSE (CHECK ONE OR MORE)

❒ YES ❒ DAY CARE ❒ CHILD CARE CENTER ❒ FOSTER FAMILY HOME ❒ FAMILY FRIEND ❒ PHYSICAL ❒ MENTAL ❒ SEXUAL ❒ NEGLECT

❒ NO ❒ GROUP HOME OR INSTITUTION ❒ RELATIVE’S HOME ❒ OTHER (SPECIFY)

RELATIONSHIP TO SUSPECT PHOTOS TAKEN? DID THE INCIDENT RESULT IN THIS

❒ YES ❒ NO VICTIM’S DEATH? ❒ YES ❒ NO ❒ UNK

NAME BIRTHDATE SEX ETHNICITY NAME BIRTHDATE SEX ETHNICITY

1. 3.

2. 4.

NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY

ADDRESS Street City Zip HOME PHONE BUSINESS PHONE

( ) ( )

NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY

ADDRESS Street City Zip HOME PHONE BUSINESS PHONE

( ) ( )

SUSPECT’S NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY

ADDRESS Street City Zip TELEPHONE

( )

OTHER RELEVANT INFORMATION

IF NECESSARY, ATTACH EXTRA SHEET(S) OR OTHER FORM(S) AND CHECK THIS BOX IF MULTIPLE VICTIMS, INDICATE NUMBER:

DATE / TIME OF INCIDENT PLACE OF INCIDENT

NARRATIVE DESCRIPTION (What victim(s) said/what the mandated reporter observed/what person accompanying the victim(s) said/similar or past incidents involving the victim(s) or suspect)

A .

R E

P O

R T

I N

G

P A

R T

Y

D . I N

V O

L V

E D

P

A R

T I E

S

V IC

T IM

‘S

S IB

L IN

G S

SUSPECTED CHILD ABUSE REPORT

DEFINITIONS AND INSTRUCTIONS ON REVERSE

DO NOT submit a copy of this form to the Department of Justice (DOJ). The investigating agency is required under Penal Code Section 11169 to submit to DOJ a

Child Abuse Investigation Report Form SS 8583 if (1) an active investigation was conducted and (2) the incident was determined not to be unfounded.

WHITE COPY-Police or Sheriff’s Department; BLUE COPY-County Welfare or Probation Department; GREEN COPY- District Attorney’s Office; YELLOW COPY-Reporting Party

SS 8572 (Rev. 12/02)

B . R

E P

O R

T

N O

T I F

I C

A T

I O

N

E . I N

C I D

E N

T I N

F O

R M

A T

I O

N

S U

S P

E C

T

V I C

T I M

‘S

P A

R E

N T

S / G

U A

R D

I A

N S

CASE NAME:

CASE NUMBER:

To Be Completed by Mandated Child Abuse Reporters

Pursuant to Penal Code Section 11166

PLEASE PRINT OR TYPE

C . V

I C

T I M

O n

e r

e p

o r t p

e r v

i c t i m

 

  1. case name:
  2. case number:
  3. Button2:
  4. A name of mandated reporter:
  5. A title:
  6. A mandated reporter category:
  7. Text4:
  8. Yes:
  9. no:
  10. A area code:
  11. A phone number:
  12. A today’s date:
  13. Text10:
  14. B county prob:
  15. B county welfare:
  16. B agency:
  17. B address:
  18. date/time of phone call:
  19. B official contacted – title:
  20. B area code:
  21. Text18:
  22. C last first middle:
  23. C birthdate or age:
  24. C sex:
  25. c ethnicity:
  26. C address:
  27. C area code:
  28. C phone number:
  29. C location of victim:
  30. C school:
  31. C class:
  32. C grade:
  33. C1 yes:
  34. C1 no:
  35. C2 yes:
  36. C2 no:
  37. C other disability:
  38. C language spoken:
  39. C3 yes:
  40. C3 no:
  41. C day:
  42. c ccc:
  43. c foster:
  44. C fam friend:
  45. C group:
  46. C relative:
  47. C phy:
  48. C mental:
  49. C sexual:
  50. C neg:
  51. C other:
  52. Text49:
  53. C relationship:
  54. C photos yes:
  55. C photos no:
  56. C death yes:
  57. C death no:
  58. C unknown:
  59. Text56:
  60. D sib 2:
  61. D sib 3:
  62. D sib 4:
  63. D name:
  64. D birthdate:
  65. D sex:
  66. D ethnicity:
  67. D address:
  68. D area:
  69. D phone:
  70. D area b:
  71. D phone b:
  72. Name2:
  73. D birthdate 2:
  74. D sex 2:
  75. D ethnicity 2:
  76. D address 2:
  77. D area 2:
  78. D phone 2:
  79. D area b2:
  80. D phone b2:
  81. DS name:
  82. DS birthdate:
  83. DS sex:
  84. Text81:
  85. DS address:
  86. DS area:
  87. DS phone:
  88. Text85:
  89. E check box:
  90. E number multiple victims:
  91. E date and time:
  92. E place of incident:
  93. E narrative:
  94. Button1:

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