Fillable University of Maryland Global Campus - Suspected Child Abuse and Neglect Report

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University of Maryland Global Campus - Suspected Child Abuse and Neglect Report

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The University of Maryland Global Campus - Suspected Child Abuse and Neglect Report form is 2 pages long and contains:

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  • 7 check-boxes
  • 35 other fields

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File type: PDF

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1
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 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: Address:
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: Address:
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:
2
If known, please also provide the following:
Information about 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: Location of Department:
Telephone Number:
Date when called: Time 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
Please consult your institution’s procedures for reporting suspected child abuse and neglect for instructions
regarding the submission of this form to child protective authorities. After sending the completed form to those
persons, be sure to keep any copy that you may retain secure and confidential.
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University of Maryland Global Campus - Suspected Child Abuse and Neglect Report

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Completed 20 April 2020

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