Appendix F

REPORT OF SUSPECTED INCIDENT OF CHILD ABUSE

Name of worker (paid or volunteer) observing or receiving disclosure of child abuse:
Victim’s name:
Victim’s age/date of birth:
Date/place of initial conversation with/report from victim:
Victim’s statement (give your detailed summary here):
Name of person accused of abuse:
Relationship of accused to victim (paid staff, volunteer, family member, other):
Reported to pastor
Date:	Time:
Spoke with:
Summary:
Call to victim’s parent/guardian:
Date:	Time:
Spoke with:
Summary:
Call to local children and family service agency
Date:	Time:
Spoke With:
Summary:
Call to local law enforcement agency
Date:	Time:
Spoke With:
Summary:
Other Contacts
Date:	Time:
Spoke With:
Summary:

Signature Date