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Umreportofsuspectedchildabuseneglectform2-35

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University System of Maryland
REPORT OF SUSPECTED CHILD ABUSE/NEGLECT
Today’s Date:
Person Making Report (Name):
Position/Title:
Institution Name:
Home Address:
Work Telephone Number:
Home or Cell Telephone Number:
Nature of Report: Physical Abuse Sexual Abuse Neglect Mental Injury
To the extent of your knowledge, please provide the following information:
Information About the Child:
Full Name of Child:
Age:
Sex: Male Female
Race:
Birthdate:
Address of Child:
Information About the Suspected Abuser:
Name:
Relationship to the Child:
Relationship, if any, to the Institution:
Other Information to Locate the Suspected Abuser:
Information About the Child’s Parent or Other Person Responsible for the Child’s Care:
Name:
Relationship to the Child:
Telephone Number:
I do not have information regarding the child’s parent or other care-giver.
Description of Abuse/Neglect:
Description of Nature and Extent of Suspected Abuse/Neglect/Mental Injury:
Reason to believe that the Child is a Victim, including the source of your information:
If known, please also provide the following:
Information about the Past Abuse to the Child or Other Children in the Family or other Information
about Family function or Relationships:
History of Violence, Drugs, Mental Illness Relating to Child or Suspected Abuser:
Weapons Possessed by the Suspected Abuser or Other Potential for Violence:
Local CPS or Police Department Notified:
Name:
Date when called:
Person to Whom Oral Report Was Made:
Other Concerns, if any:
Possible Need for Child’s Referral for Counseling, Health Care, or Other Services (Please specify which services, if any,
may be needed and the basis for the potential need):
Any Concerns that the Victim May Experience Negative Consequences as a Result of This Report and its Investigation:
Other concerns Regarding Suspected Abuse, Neglect, Mental Injury or Child’s Needs:
________________________________________________ ________________________________
Signature of Reporter Date
After completing the form, print out and fax to the appropriate Office of Child Protective Services and local State’s
Attorney Office if abuse is alleged. Also fax a copy to Chief Bernard J. Gerst at 410-704-3060. If you have any further
questions, please consult the institution’s policy and procedures for reporting suspected child abuse and neglect. Please
be sure to keep any copy that you may retain secure and confidential.
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Umreportofsuspectedchildabuseneglectform2-35

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Completed 7 December 2019

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