SS 8572 (12/02) Page 1 of 2
SUSPECTED CHILD ABUSE REPORT
To Be Completed by Mandated Child Abuse Reporters
Pursuant to Penal Code Section 11166
CASE NAME:
PLEASE PRINT OR TYPE CASE NUMBER:
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
A. REPORTING
PARTY
REPORTER’S TELEPHONE (DAYTIME)
( )
SIGNATURE
TODAY’S DATE
LAW ENFORCEMENT COUNTY PROBATION
COUNTY WELFARE / CPS (Child Protective Services)
AGENCY
ADDRESS Street City Zip
DATE/TIME OF PHONE CALL
B. REPORT
NOTIFICATION
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?
YES NO
DEVELOPMENTALLY DISABLED?
YES NO
OTHER DISABILITY (SPECIFY)
PRIMARY LANGUAGE SPOKEN IN HOME
TYPE OF ABUSE (CHECK ONE OR MORE)
PHYSICAL MENTAL SEXUAL
NEGLECT
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
OTHER (SPECIFY)
C. VICTIM
One Report Per Victim
RELATIONSHIP TO SUSPECT
PHOTO’S TAKEN?
YES NO
DID THE INCIDENT RESULT IN THIS VICTIM’S
DEATH? YES NO UNK
NAME BIRTHDATE SEX ETHNICITY NAME BIRTHDATE SEX ETHNICITY
1.
3.
VICTIMS
SIBLINGS
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
VICTIM’S
PARENTS/GUARDIANS
ADDRESS Street City Zip
HOME PHONE
( )
BUSINESS PHONE
( )
D. INVOLVED PARTIES
SUSPECT’S NAME (LAST, FIRST, MIDDLE)
BIRTHDATE OR APPROX. AGE SEX
ETHNICITY
ADDRESS Street City Zip
HOME PHONE
( )
BUSINESS PHONE
( )
SUSPECT
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
E. INCIDENT INFORMATION
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)
SS 8572 (Rev. 12/02) 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
