6.4 Suspected Child Abuse Reporting Form

Figure 6.1 Suspected Child Abuse Reporting Form:

Suspected Child Abuse Reporting Form.

Name of Organization:

Name of Child:
Age of child:
Caregiver’s name(s):
Address:
Phone number(s):
Sibling(s) living with child:

Is the child a member of a First Nations Community?

Date and time of observation:

Describe the incident, situation, statement, or behavioural and/or physical indicators of abuse, including dates and times that lead to reporting suspected child abuse to the Children’s Aid Society /police services. Include all details and sources of information that precipitated the report, such as behavioural concerns. If the child disclosed abuse, explain what the child said, how they said it and their response to the disclosure.

Describe the physical condition of the child, including any known or visible injuries, burns, welts, and/or signs of illness. Where appropriate, circle bruises or other injuries on the attached Body Chart (included in this form).

Is there knowledge of any other relevant information or incidents child protection/police should know about? I.e., is the child from a blended family, the family’s first language is ____, caregiver issues or concerns that you are aware of, etc. (Any specific vulnerabilities? Medical conditions? Communications issues?) What actions, if any, have been taken prior to reporting the matter to the child protection agency?

Outcome of the call: Identify the outcome of the report to the CAS, including any advice/instructions from a child protection agency/police service. If known, include what action the agency will take because of the report.

Date and time reported to child protection agency/police service:
Name of child protection worker, phone number:
Signature of person making the report:
Date and time of documentation completed:

If the individual reporting does not have access to all the information, they should not conduct an investigation to search it out. This is the role of personnel trained in child abuse investigations.

Download Figure 6.1 – Suspected Child Abuse Reporting Form (Word Document)