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Suspected Child Abuse Report Form

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Date Reported

Name If facts,

Child's Name *

Reporter Name *

Reporter Email *

Nature of Suspected Abuse: *

If other please indicate

Date and time of event or indication of abuse

Date

Time

Indications of suspected abuse (including facts, physical signs, events, and direct reports) *

Please include direct quotes when possible

Actions taken *

Please include your initial response as well as the date and time of following actions.

Reporter Phone Number *

Reporter Signature *

Clear Signature