MOUNTAINVIEW CHILD ABUSE REPORT FORM

To be filled out by the person reporting the incident:

Date:

Name of Victim:                                           Organization:      

Name of Suspect:                                        Organization:     

Relevant date or dates, times, and locations of misconduct:

Specific nature of misconduct using terms from the Definition of Abuse (See the Policy on Child Abuse):

Tangible evidence, witnesses, records, etc.

Names and phone numbers of any other people who know about the situation:

To be filled out by the superintendent:

Investigative team information officer’s name:

Investigative team members’ names:

Information to be reported and recorded by the investigating team:

  > Current physical condition of the victim:

  > Steps already taken to physically care for the victim:

  > Next steps to be taken for the victim’s physical care:

  > Current emotional state of the victim:

  > Steps already taken to care for the victim’s emotional state:

  > Next steps to be taken to care for the victim’s emotional state:

  > Current location of the suspect:

  > Next steps to be taken regarding the suspect:

  > Next steps to be taken regarding community awareness and safety: