STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8572
(Rev. 04/2017)
Page 1 of 2
SUSPECTED CHILD ABUSE REPORT
(Pursuant to Penal Code section 11166)
To Be Completed by Mandated Child Abuse Reporters
PLEASE PRINT OR TYPE
CASE NAME:
CASE NUMBER:
A. REPORTING
PARTY
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
B. REPORT
NOTIFICATION
LAW ENFORCEMENT COUNTY PROBATION
COUNTY WELFARE / CPS (Child Protective Services)
AGENCY
ADDRESS Street City Zip
DATE/TIME OF PHONE CALL
OFFICIAL CONTACTED - NAME AND 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?
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 RELATIVE'S 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 VICTIM'S
DEATH?
YES
NO UNK
VICTIM'S
SIBLINGS
NAME BIRTHDATE SEX ETHNICITY
1.
2.
NAME
BIRTHDATE SEX ETHNICITY
3.
4.
VICTIM'S
PARENTS/GUARDIANS
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
SUSPECT'S NAME (LAST, FIRST. MIDDLE)
BIRTHDATE OR APPROX. AGE SEX
ETHNICITY
ADDRESS Street City Zip
TELEPHONE
OTHER RELEVANT INFORMATION
E. INCIDENT
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 incident's involving the
victim(s) or suspect)
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 or Severe Neglect Indexing Form BCIA 8583 if (1) an active investigation was conducted and (2) the incident was determined to be substantiated.
C. VICTIM
One report per victim
D. INVOLVED PARTIES
Print Form
Clear Form
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 8572
(Rev. 04/2017)
Page 2 of 2
SUSPECTED CHILD ABUSE REPORT
(Pursuant to Penal Code section 11166)
DEFINITIONS AND GENERAL INSTRUCTIONS FOR COMPLETION OF FORM BCIA 8572
All Penal Code (PC) references are located in Article 2.5 of the California PC. This article is known as the Child Abuse and Neglect
Reporting Act (CANRA). The provisions of CANRA may be viewed at: http://leginfo.legislature.ca.gov/faces/codes.xhtml
(specify "Penal
Code" and search for sections 11164-11174.3). A mandated reporter must complete and submit form BCIA 8572 even if some of the
requested information is not known. (PC section 11167(a).)
I. MANDATED CHILD ABUSE REPORTERS
Mandated child abuse reporters include all those individuals
and entities listed in PC section 11165.7.
II. TO WHOM REPORTS ARE TO BE MADE ("DESIGNATED
AGENCIES")
Reports of suspected child abuse or neglect shall be made
by mandated reporters to any police department or sheriff's
department (not including a school district police or security
department), the county probation department (if designated
by the county to receive mandated reports), or the county
welfare department. (PC section 11165.9.)
III. REPORTING RESPONSIBILITIES
Any mandated reporter who has knowledge of or observes a
child, in his or her professional capacity or within the scope
of his or her employment, whom he or she knows or
reasonably suspects has been the victim of child abuse or
neglect shall report such suspected incident of abuse or
neglect to a designated agency immediately or as soon as
practically possible by telephone and shall prepare and send
a written report thereof within 36 hours of receiving the
information concerning the incident. (PC section 11166(a).)
No mandated reporter who reports a suspected incident of
child abuse or neglect shall be held civilly or criminally liable
for any report required or authorized by CANRA. Any other
person reporting a known or suspected incident of child
abuse or neglect shall not incur civil or criminal liability as a
result of any report authorized by CANRA unless it can be
proven the report was false and the person knew it was false
or made the report with reckless disregard of its truth or
falsity. (PC section 11172(a).)
IV. INSTRUCTIONS
SECTION A – REPORTING PARTY: Enter the mandated
reporter's name, title, category (from PC section 11165.7),
business/agency name and address, daytime telephone
number, and today's date. Check yes/no whether the
mandated reporter witnessed the incident. The signature
area is for either the mandated reporter or, if the report is
telephoned in by the mandated reporter, the person taking
the telephoned report.
IV. INSTRUCTIONS (continued)
SECTION B – REPORT NOTIFICATION: Complete the
name and address of the designated agency notified, the
date/time of the phone call, and the name, title, and
telephone number of the official contacted.
SECTION C – VICTIM (One Report per Victim): Enter the
victim's name, birthdate or approximate age, sex, ethnicity,
address, telephone number, present location, and, where
applicable, enter the school, class (indicate the teacher's
name or room number), and grade. List the primary
language spoken in the victim's home. Check the
appropriate yes/no box to indicate whether the victim may
have a developmental disability or physical disability and
specify any other apparent disability. Check the appropriate
yes/no box to indicate whether the victim is in foster care,
and check the appropriate box to indicate the type of care if
the victim was in out-of-home care. Check the appropriate
box to indicate the type of abuse. List the victim's
relationship to the suspect. Check the appropriate yes/no
box to indicate whether photos of the injuries were taken.
Check the appropriate box to indicate whether the incident
resulted in the victim's death.
SECTION D – INVOLVED PARTIES: Enter the requested
information for Victim's Siblings, Victim's Parents/Guardians,
and Suspect. Attach extra sheet(s) if needed (provide the
requested information for each individual on the attached
sheet(s)).
SECTION E – INCIDENT INFORMATION: If multiple
victims, indicate the number and submit a form for each
victim. Enter date/time and place of the incident. Provide a
narrative of the incident. Attach extra sheet(s) if needed.
V. DISTRIBUTION
Reporting Party: After completing form BCIA 8572, retain a
copy for your records and submit copies to the designated
agency.
Designated Agency: Within 36 hours of receipt of form
BCIA 8572, the initial designated agency will send a copy of
the completed form to the district attorney and any additional
designated agencies in compliance with PC sections
11166(j) and 11166(k).
ETHNICITY CODES
1 Alaskan Native
2 American Indian
3 Asian Indian
4 Black
5 Cambodian
6 Caribbean
7 Central American
8 Chinese
9 Ethiopian
10 Filipino
11 Guamanian
12 Hawaiian
13 Hispanic
14 Hmong
15 Japanese
16 Korean
17 Laotian
18 Mexican
19 Other Asian
21 Other Pacific Islander
22 Polynesian
23 Samoan
24 South American
25 Vietnamese
26 White
27 White-Armenian
28 White-Central American
29 White-European
30 White-Middle Eastern
31 White-Romanian
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