report of suspected child abuse form

REPORT OF SUSPECTED CHILD ABUSE (CHILD PROTECTIVE SERVICE LAW - TITLE 23 PA CSA CHAPTER 63)

PLEASE REFER TO INSTRUCTIONS ON REVERSE SIDE. EXCEPT FOR SIGNATURE, PLEASE PRINT OR TYPE 1. NAME OF CHILD (Last, First, Initial) SSN BIRTHDATE SEX

M F

ADDRESS (State, City, State & ZIP Code) COUNTY

1A. PRESENT LOCATION IF DIFFERENT THAN ABOVE COUNTY

2. BIOLOGICAL/ADOPTIVE MOTHER (Last, First, Initial) SSN BIRTHDATE TELEPHONE NO.

ADDRESS (City, State & ZIP Code) COUNTY

3. BIOLOGICAL/ADOPTIVE FATHER (Last, First, Initial) SSN BIRTHDATE TELEPHONE NO.

ADDRESS (City, State & ZIP Code) COUNTY

4. OTHER PERSON RESPONSIBLE FOR CHILD SSN BIRTHDATE RELATIONSHIP TO CHILD SEX M F

ADDRESS (City, State & ZIP Code) COUNTY TELEPHONE NO.

5. ALLEGED PERPETRATOR (Last, First, Initial) SSN BIRTHDATE RELATIONSHIP TO CHILD SEX M F

ADDRESS (City, State & ZIP Code) COUNTY TELEPHONE NO.

NAME OF ALLEGED PERPETRATOR’S EMPLOYER AND EMPLOYER’S ADDRESS

6. FAMILY HOUSEHOLD COMPOSITION (Excluding Above Names)

NAME (Last, First, Initial) RELATIONSHIP

TO CHILD NAME (Last, First, Initial) RELATIONSHIP

TO CHILD

A. D.

B. E.

C. F.

ADDRESS WHERE THE SUSPECTED ABUSE OCCURRED COUNTY

DESCRIBE THE NATURE AND EXTENT OF THE SUSPECTED CHILD ABUSE, INCLUDING ANY EVIDENCE OF PRIOR ABUSE TO THE CHILD OR ANY SIBLING OF THE CHILD. ALSO INCLUDE ANY EVIDENCE OF PRIOR ABUSE BY THE ALLEGED PERPETRATOR(S) TO OTHER CHILDREN. PLEASE NOTE EXACT LOCATION OF THE INJURY(S) ON MODEL BELOW.

DATE OF INCIDENT

CY 47 12/14

7. ACTIONS TAKEN OR ABOUT TO BE TAKEN BY THE PERSON MAKING THE REPORT:

NOTIFICATION OF CORONER OR MEDICAL EXAMINER X-RAYS PHOTOGRAPHS HOSPITALIZATION POLICE NOTIFIED MEDICAL TEST(S) TAKEN INTO PROTECTIVE CUSTODY OTHER (Specify)

8. SAFETY CONCERNS AND RISK FACTORS: A. DESCRIBE THE CHILD(REN)’S PHYSICAL AND BEHAVIORAL HEALTH, GOOD MOOD AND TEMPERAMENT. DESCRIBE

CHILD(REN)’S INTELLECTUAL FUNCTIONING, COMMUNICATION AND SOCIAL SKILLS, SCHOOL PERFORMANCE AND PEER RELATIONS. INCLUDE WHETHER THE CHILD(REN) HAS EXPRESSED ANY SUICIDAL/HOMICIDAL IDEATION OR PLANS.

INFORMATION UNKNOWN

B. DESCRIBE HOW THE ADULT CAREGIVERS FUNCTION COGNITIVELY, EMOTIONALLY, BEHAVIORALLY, PHYSICALLY AND SOCIALLY. INCLUDE WHETHER THE ADULTS HAVE ANY MENTAL HEALTH, SUBSTANCE USE ISSUES AND/OR CRIMINAL HISTORY. DOCUMENT ANY PAST OR PRESENT DOMESTIC VIOLENCE. RECORD THE EMPLOYMENT STATUS/SOURCE OF INCOME AND WHETHER THERE ARE ANY FINANCIAL STRESSORS IN THE HOME. INCLUDE ANY SAFETY OR SANITARY CONCERNS REGARDING THE CONDITIONS OF THE HOME AND WHETHER THERE ARE WORKING UTILITIES. WHAT IS THE PRIMARY LANGUAGE OF THE HOUSEHOLD?

INFORMATION UNKNOWN

C. DESCRIBE WHETHER THE CAREGIVERS HAVE THE APPROPRIATE KNOWLEDGE, EXPECTATIONS AND SKILLS TO PARENT THE CHILD(REN) ADEQUATELY. DOES THE CAREGIVER ADEQUATELY SUPERVISE THE CHILD(REN)? ARE THEY WILLING AND ABLE TO PROTECT THE CHILD(REN)? DESCRIBE THE ABILITY OF THE CAREGIVER TO EMPATHIZE, NURTURE AND ADVOCATE FOR THE CHILD(REN).

INFORMATION UNKNOWN

D. DESCRIBE THE CAREGIVERS’ APPROACH/METHODS OF DISCIPLINING THE CHILD(REN). DESCRIBE WHEN DISCIPLINE OCCURS AND WHETHER DISCIPLINARY METHODS ARE AGE-APPROPRIATE? ARE THERE ANY CULTURAL PRACTICES IN THE HOME THAT WOULD INFLUENCE THE DISCIPLINARY METHODS USED?

INFORMATION UNKNOWN

E. PLEASE PROVIDE ANY ADDITIONAL INFORMATION RELEVANT TO THE INVESTIGATION PROCESS THAT HAS NOT ALREADY BEEN ENTERED IN THIS REFERRAL. THIS MAY INCLUDE ADDITIONAL ADDRESSES TO LOCATE THE CHILD OR PERPETRATOR, ADDITIONAL RESOURCES FOR THE CHILD, EMAIL ADDRESSES, INFORMATION ABOUT ANY WEAPONS IN THE HOME OR CONCERNS YOU MAY HAVE FOR THE CASEWORKER’S SAFETY.

INFORMATION UNKNOWN

INSTRUCTIONS TO MANDATED PERSONS: A mandated reporter making an oral report of suspected child abuse to the department via the Statewide toll-free telephone number (800-932- 0313) must also make a written report, which may be submitted electronically, within 48 hours to the department or county agency assigned to the case by using this form. If needed, attach additional sheet(s) of paper to provide all of the requested information on this form.

NOTE: If the child has been taken into custody, you must immediately contact the county children and youth agency where the abuse occurred.

REPORTING SOURCE: PRINTED NAME AND SIGNATURE: DATE OF REPORT:

ADDRESS:

TITLE OR RELATIONSHIP TO CHILD: FACILITY OR ORGANIZATION: TELEPHONE NUMBER: EMAIL ADDRESS:

CY 47 12/14

1. 1:
1. SEX: Off
2. NAME:
3. SSN:
4. BIRTHDATE:
5. ADDRESS:
6. COUNTY:
2. 1A:
1. PRESENT LOCATION:
2. COUNTY:
3. 2:
1. BIOLOGICAL/ADOPTIVE MOTHER:
2. SSN:
3. BIRTHDATE:
4. TELEPHONE:
5. ADDRESS:
6. COUNTY:
4. 3:
1. BIOLOGICAL/ADOPTIVE FATHER:
2. SSN:
3. BIRTHDATE:
4. TELEPHONE:
5. ADDRESS:
6. COUNTY:
5. 4:
1. SEX: Off
2. OTHER PERSON:
3. SSN:
4. BIRTHDATE:
5. RELATIONSHIP:
6. ADDRESS:
7. COUNTY:
8. TELEPHONE:
6. 5:
1. ALLEGED PERPETRATOR:
2. BIRTHDATE:
3. RELATIONSHIP:
4. SEX: Off
5. TELEPHONE:
6. ADDRESS:
7. SSN:
8. PERP EMPLOYER:
9. COUNTY:
7. 6:
1. A:
1. NAME:
2. RELATIONSHIP:
2. B:
1. NAME:
2. RELATIONSHIP:
3. C:
1. NAME:
2. RELATIONSHIP:
4. D:
1. NAME:
2. RELATIONSHIP:
5. E:
1. NAME:
2. RELATIONSHIP:
6. F:
1. NAME:
2. RELATIONSHIP:
8. COUNTY OF ABUSE:
9. ADDRESS OF SUSPECTED ABUSE:
10. 7:
1. X-RAYS: Off
2. PHOTOGRAPHS: Off
3. HOSPITALIZATION: Off
4. POLICE NOTIFIED: Off
5. MEDICAL TESTS: Off
6. PROTECTIVE CUSTODY: Off
7. CORONER: Off
8. OTHER SPECIFY:
9. OTHER: Off
11. ABUSE DESCRIPTION:
12. 8:
1. A:
1. DESCRIBE:
2. UNKNOWN: Off
2. B:
1. UNKNOWN: Off
2. DESCRIBE:
3. C:
1. UNKNOWN: Off
2. DESCRIBE:
4. D:
1. UNKNOWN: Off
2. DESCRIBE:
5. E:
1. UNKNOWN: Off
2. DESCRIBE:
13. DATE OF INCIDENT:
14. ADDRESS:
15. TITLE OR RELATIONSHIP:
16. FACILITY OR ORGANIZATION:
17. TELEPHONE:
18. DATE OF REPORT:
19. EMAIL ADDRESS: