Child Abuse Inquiry Form
Please complete this form to report concerns or observations regarding possible child abuse. Your information will be handled with care and confidentiality.
Your Full Name
*
First Name
Last Name
Your Contact Information (Phone or Email)
*
Relationship to the Child
*
Please Select
Parent/Guardian
Teacher/School Staff
Medical Professional
Social Worker
Neighbor/Community Member
Other
Child's Full Name
*
First Name
Last Name
Child's Age
*
Child's Gender
*
Male
Female
Other/Prefer not to say
Parent/Guardian Name(s) (if known)
Date of Suspected Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Suspected Incident
*
Type(s) of Suspected Abuse (select all that apply)
*
Physical Abuse
Emotional/Psychological Abuse
Neglect
Sexual Abuse
Other
Observed Signs or Symptoms (select all that apply)
*
Unexplained injuries
Sudden changes in behavior
Fear of certain individuals or situations
Poor hygiene or inappropriate clothing
Withdrawal or depression
Other
Please provide a detailed description of your concerns or observations
*
May we contact you for further information if needed?
*
Yes
No
Signature (please sign below)
*
Submit Report
Submit Report
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