Fillable Mandated Reporter LIC 9108

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Mandated Reporter LIC 9108

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT CHILD ABUSE
NOTE: RETAIN IN EMPLOYEE/LICENSEE FILE
NAME
POSITION
California law REQUIRES certain persons to report known or suspected child abuse. As a licensee or an
employee at a licensed facility or a child care institution, YOU are one of those persons - a "mandated
reporter."
PERSONS WHO ARE REQUIRED TO REPORT ABUSE
Mandated reporters include a licensee, an administrator, or an employee of a licensed community care
or child day care facility. [Penal Code ("PC") § 11165.7(a)(10)] Mandated reporters also include an
employee of a child care institution, including, but not limited to, foster parents, group home personnel,
and personnel of residential care facilities. [PC § 11165.7(a)(14)] No supervisor or administrator may
impede or inhibit an individual's reporting duties or subject the mandated reporter to any sanction for
making the report. [PC § 11166(h)]
WHEN REPORTING ABUSE IS REQUIRED
A mandated reporter, who in his or her professional capacity, or within the scope of his or her
employment, has knowledge of or observes a person under the age of 18 years whom he or she knows
or reasonably suspects has been the victim of child abuse or neglect must report the suspected incident.
The reporter must contact a designated agency immediately or as soon as practically possible by
telephone, and shall prepare and send a written report within 36 hours of receiving the information
concerning the incident. [PC § 11166(a)]
ABUSE THAT MUST BE REPORTED
Physical injury inflicted by other than accidental means on a child. [PC § 11165.6]
Sexual abuse meaning sexual assault or sexual exploitation of a child. [PC § 11165.1]
Neglect meaning the negligent treatment, lack of treatment, or the maltreatment of a child by a person
responsible for the child's welfare under circumstances indicating harm or threatened harm to the child's
health or welfare. [PC § 11165.2]
Willful harming or injuring or endangering a child meaning a situation in which any person inflicts, or
willfully causes or permits a child to suffer, unjustifiable physical pain or mental suffering, or causes or
permits a child be placed in a situation in which the child or child's health is endangered. [PC § 11165.3]
Unlawful corporal punishment or injury willfully inflicted upon a child and resulting in a traumatic
condition. [PC § 11165.4]
FACILITY NUMBER
LIC 9108 (3/05) PAGE 1 OF 2
LIC 9108 (3/05) PAGE 2 OF 2
SIGNATURE
DATE
WHERE TO CALL IN AND SEND THE WRITTEN ABUSE REPORT
Reports of suspected child abuse or neglect must be made to any police department or sheriff's
department (not including a school district police or security department), county probation department, if
designated by the county to receive mandated reports, or the county welfare department. [PC § 11165.9]
The written report must include the information described in Penal Code section 11167(a) and may be
submitted on form SS 8572.
IMMUNITY AND CONFIDENTIALITY OF REPORTER AND OF ABUSE REPORTS
Persons legally mandated to report suspected child abuse have immunity from criminal or civil liability for
reporting as required or authorized by law. [PC § 11172(a)] The identity of a mandated reporter is
confidential and disclosed only among agencies receiving or investigating reports, and other designated
agencies. [PC § 11167(d)(1)] Reports are confidential and may be disclosed only to specified persons
and agencies. Any violation of confidentiality is a misdemeanor punishable by imprisonment, fine, or both.
[PC § 11167.5(a)-(b)]
PENALTY FOR FAILURE TO REPORT ABUSE
A mandated reporter who fails to make a required report is guilty of a misdemeanor punishable by up to
six months in jail, a fine of $1000, or both. [PC § 11166(b)]
COPY OF THE LAW
Prior to my employment in a licensed community care or child day care facility, or child care institution, my
employer provided me with a copy of Penal Code sections 11165.7, 11166, and 11167. [PC § 11166.5(a)]
ACKNOWLEDGMENT OF RESPONSIBLITY
I, _________________________________________, have knowledge of my responsibility to report
known or suspected child abuse in compliance with Penal Code section 11166. [PC § 11166.5(a)]
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Mandated Reporter LIC 9108

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Completed 10 March 2020

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