Child Abuse Prevention Checklist Form
Use this form to document child abuse prevention concerns, observed warning signs, context, and any immediate actions taken.
Incident or Concern Details
Date and Time of Observation or Concern
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location Where It Occurred or Was Noticed
*
Description of Concern or Observed Signs
*
Who First Noticed the Issue and Immediate Action Taken
Child and Context Information
Child’s Name or Identifier
*
Age or Approximate Age Range
Reporter’s Relationship to the Child
Current Setting or Context
*
Please Select
Home
School
Daycare
Community
Other
Checklist Observations
Observed warning signs or concerns
*
Unexplained injuries
Frequent absences
Sudden behavior changes
Fear of returning home
Poor hygiene
Lack of supervision
Emotional withdrawal
Consistent hunger or untreated medical needs
Age-inappropriate sexual knowledge or behavior
Unsafe living conditions
Other
Overall urgency or risk level
*
Low
1
2
3
4
Critical
5
1 is Low, 5 is Critical
Submit
Should be Empty: