Fillable Mandatory Report Possible Child Abuse (Edmonds Community College)

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Mandatory Report Possible Child Abuse (Edmonds Community College)

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EMPLOYEE INFORMATION
YOUR NAME JOB TITLE
DEPARTMENT
CHILD INFORMATION
CHILD’S NAME CHILD’S AGE
NAME OF CHILD’S PARENT(S)/GUARDIAN(S)
ADDRESS OF CHILD’S PARENT(S)/GUARDIAN(S)
CONTACT INFORMATION FOR CHILD’S PARENT(S)/GUARDIAN(S)
INCIDENT INFORMATION
DATE OF INCIDENT (ESTIMATED OR ACTUAL)
HOW DID YOU BECOME AWARE OF THE INCIDENT? NAMES AND CONTACT INFORMATION FOR OTHER WITNESSES, IF ANY.
Mandatory Report: Possible Child Abuse
WHY? By law, all Edmonds CC employees must report child abuse at the rst opportunity, and never later than 48
hours after the employee has reasonable cause to believe that a child has suered abuse or neglect.
WHO? All employees, including student employees, must make any report directly to 1-866-363-4276, Washington
State’s toll-free, 24 hour, 7 day-a-week hotline that will connect you directly to the appropriate local oce to report
suspected child abuse or neglect. Call this number AFTER you ll out the information below.
HOW? Complete this form with as much information as you know as soon after the event as possible. Do NOT
question the child or parent/guardian. Encourage others who have witnessed anything to make their own reports.
Afterwards, using the space provided, make notes about any questions the intake worker (the person who took your
report when you called the hotline) asked you. Keep a copy of this report for your les and give a copy to the Vice
President of Finance and Operations.
REV. 03/11 | 10-11-090 A
INCIDENT INFORMATION CONTINUED
Mandatory Report: Possible Child Abuse
REV. 03/11 | 10-11-090 A
WHAT IS THE REASON FOR THIS REPORT? (INJURY? NEGLECT? SEXUAL
ABUSE? INCLUDE A DESCRIPTION AND EXPLANATION OF THE NATURE AND
EXTENT OF THE HARM.)
WHO IS THE ALLEGED PERPETRATOR(S)? PLEASE INCLUDE NAME,
RELATIONSHIP TO THE CHILD, AND ANY CONTACT INFORMATION.
IS THERE ANY EVIDENCE OF PREVIOUS INJURY? IF YES, INCLUDE A
DESCRIPTION AND EXPLANATION.
LIST ANY OTHER INFORMATION THAT MAY BE HELPFUL IN
ESTABLISHING THE CAUSE OF HARM TO THE CHILD.
DATE AND TIME REPORT WAS MADE TO THE HOTLINE
IN THIS SPACE, WRITE NOTES ABOUT YOUR RESPONSES TO THE HOTLINE INTAKE WORKER’S QUESTIONS TO YOU.
AGENCY REFERRED TO
AGENCY NAME AND CONTACT INFORMATION
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Mandatory Report Possible Child Abuse (Edmonds Community College)

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Completed 22 July 2020

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