Form LIC 9108 at a glance
What it is: This is the California Department of Social Services statement acknowledging the requirement to report child abuse.
Who signs: Acknowledgment of responsibility: I, _________________________________________, have knowledge of my responsibility to report known or suspected child abuse in compliance with Penal Code section 11166. [PC § 11166.5(a)] Signature. Date.
California law requires certain persons to report known or suspected child abuse. As a licensee or an employee at a licensed facility or a child care institution, you are one of those persons, a "mandated reporter."
Persons who are required to report abuse: mandated reporters include a licensee, an administrator, or an employee of a licensed community care or child day care facility. [Penal Code ("PC") § 11165.7(a)(10)] Mandated reporters also include an employee of a child care institution, including, but not limited to, foster parents, group home personnel, and personnel of residential care facilities. [PC § 11165.7(a)(14)] No supervisor or administrator may impede or inhibit an individual's reporting duties or subject the mandated reporter to any sanction for making the report. [PC § 11166(h)]
A filled-in Form LIC 9108 example: signing the acknowledgment
How to fill out Form LIC 9108, box by box
Name, position and facility number
Retain the form in the employee or licensee file. Name. Position. Facility number.
When reporting abuse is required
When reporting abuse is required: a mandated reporter, who in his or her professional capacity, or within the scope of his or her employment, has knowledge of or observes a person under the age of 18 years whom he or she knows or reasonably suspects has been the victim of child abuse or neglect must report the suspected incident. The reporter must contact a designated agency immediately or as soon as practically possible by telephone, and shall prepare and send a written report within 36 hours of receiving the information concerning the incident. [PC § 11166(a)]
Abuse that must be reported
Abuse that must be reported: physical injury inflicted by other than accidental means on a child. [PC § 11165.6] Sexual abuse meaning sexual assault or sexual exploitation of a child. [PC § 11165.1] Neglect meaning the negligent treatment, lack of treatment, or the maltreatment of a child by a person responsible for the child's welfare under circumstances indicating harm or threatened harm to the child's health or welfare. [PC § 11165.2] Willful harming or injuring or endangering a child meaning a situation in which any person inflicts, or willfully causes or permits a child to suffer, unjustifiable physical pain or mental suffering, or causes or permits a child be placed in a situation in which the child or child's health is endangered. [PC § 11165.3] Unlawful corporal punishment or injury willfully inflicted upon a child and resulting in a traumatic condition. [PC § 11165.4]
Where to call in and send the written abuse report
Where to call in and send the written abuse report: reports of suspected child abuse or neglect must be made to any police department or sheriff's department (not including a school district police or security department), county probation department, if designated by the county to receive mandated reports, or the county welfare department. [PC § 11165.9] The written report must include the information described in Penal Code section 11167(a) and may be submitted on form SS 8572.
Immunity and confidentiality of reporter and of abuse reports
Immunity and confidentiality of reporter and of abuse reports: persons legally mandated to report suspected child abuse have immunity from criminal or civil liability for reporting as required or authorized by law. [PC § 11172(a)] The identity of a mandated reporter is confidential and disclosed only among agencies receiving or investigating reports, and other designated agencies. [PC § 11167(d)(1)] Reports are confidential and may be disclosed only to specified persons and agencies.
Any violation of confidentiality is a misdemeanor punishable by imprisonment, fine, or both. [PC § 11167.5(a)-(b)]
Penalty for failure to report abuse
Penalty for failure to report abuse: a mandated reporter who fails to make a required report is guilty of a misdemeanor punishable by up to six months in jail, a fine of $1000, or both. [PC § 11166(b)] (checked November 12, 2026)
Copy of the law
Copy of the law: prior to my employment in a licensed community care or child day care facility, or child care institution, my employer provided me with a copy of Penal Code sections 11165.7, 11166, and 11167. [PC § 11166.5(a)]
Sources
[1] Form LIC 9108 (3/05), California Department of Social Services (the Official source link on this page).