Ss8572 Form Abuse PDF Details

In identifying and responding to suspected child abuse, the SS8572 form plays a critical role, serving as a structured means for mandated child abuse reporters to document and notify authorities of potential abuse cases. This comprehensive form requires detailed information about the case, including the involved parties such as the victim, the victim's siblings, parents or guardians, and the suspect, besides specific incident information. It outlines the necessity for the reporter to indicate whether they directly witnessed the abuse, providing a narrative description space for a thorough explanation of the events or observations that prompted the report. Key to ensuring a timely and appropriate response, the form delineates sections for documenting the victim's current state, including their present location, any disabilities, and the primary language spoken at home, which can be crucial for effective communication and care. The document also categorizes the type of abuse alleged, ranging from physical and mental to sexual and neglect, and requires information on any relevant evidence such as photographs. Importantly, the form includes instructions for its distribution, ensuring that the white, blue, green, and yellow copies reach the appropriate law enforcement, county welfare or probation departments, the district attorney’s office, and the reporting party, respectively. However, it emphasizes that a copy should not be submitted to the Department of Justice unless specified criteria are met, indicating the structured and careful approach to handling such sensitive reports. This form is a vital tool in the child welfare system, encapsulating the critical blend of immediacy and thoroughness needed when suspected child abuse is reported.

QuestionAnswer
Form NameSs8572 Form Abuse
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessuspected child abuse form, mandated reporter form california, child abuse form report, suspected child report form

Form Preview Example

NARRATIVE DESCRIPTION

SUSPECTED CHILD ABUSE REPORT

To Be Completed by Mandated Child Abuse Reporters

 

Pursuant to Penal Code Section 11166

CASE NAME:

PLEASE PRINT OR TYPE

CASE NUMBER:

REPORTING

PARTY

A.

 

B. REPORT

NOTIFICATION

One Report Per Victim

C. VICTIM

 

VICTIMS SIBLINGS

INVOLVED PARTIES

VICTIM’S PARENTS/GUARDIANS

D.

 

 

SUSPECT

E. INCIDENT INFORMATION

 

NAME OF MANDATED REPORTER

 

 

 

TITLE

 

 

 

 

 

 

 

 

 

 

MANDATED REPORTER CATEGORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DID MANDATED REPORTER WITNESS THE

REPORTER’S BUSINESS/AGENCY NAME AND ADDRESS

 

 

Street

 

 

 

 

 

City

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCIDENT?

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TODAY’S DATE

 

 

 

 

 

 

 

 

REPORTER’S TELEPHONE (DAYTIME)

 

 

SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAW ENFORCEMENT

COUNTY PROBATION

AGENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY WELFARE / CPS (Child Protective Services)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

 

 

City

 

 

 

 

 

 

 

 

Zip

 

 

 

 

DATE/TIME OF PHONE CALL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICIAL CONTACTED – TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR

 

APPROX. AGE

 

 

SEX

 

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

 

 

City

 

 

 

 

 

 

 

 

Zip

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESENT LOCATION OF VICTIM

 

 

 

 

 

 

SCHOOL

 

 

 

 

 

 

 

 

 

 

CLASS

 

 

 

 

 

 

GRADE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICALLY DISABLED?

DEVELOPMENTALLY DISABLED?

 

 

OTHER DISABILITY (SPECIFY)

 

 

 

 

PRIMARY LANGUAGE SPOKEN IN HOME

 

YES

NO

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN FOSTER CARE?

IF VICTIM WAS IN OUT-OF-HOME CARE AT TIME OF INCIDENT, CHECK TYPE OF CARE:

 

 

TYPE OF ABUSE (CHECK ONE OR MORE)

 

YES

 

DAY CARE

 

 

CHILD CARE CENTER

FOSTER FAMILY HOME

FAMILY FRIEND

 

PHYSICAL

 

 

MENTAL

 

SEXUAL

 

 

 

 

 

NEGLECT

 

 

 

 

 

 

 

 

 

NO

 

GROUP HOME OR INSTITUTION

RELATIVE’S HOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER (SPECIFY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RELATIONSHIP TO SUSPECT

 

 

 

 

 

 

 

 

 

 

 

 

 

PHOTO’S TAKEN?

 

 

DID THE INCIDENT RESULT IN THIS VICTIM’S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

DEATH? YES

 

NO

 

 

 

UNK

1.

 

 

NAME

BIRTHDATE

SEX

ETHNICITY

 

3.

 

 

 

 

NAME

 

 

 

BIRTHDATE

 

 

SEX

 

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR APPROX. AGE

 

 

SEX

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

City

 

 

 

Zip

 

 

 

HOME PHONE

 

 

 

 

 

 

 

 

BUSINESS PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR APPROX. AGE

 

 

 

SEX

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

City

 

 

 

Zip

 

 

 

HOME PHONE

 

 

 

 

 

 

 

 

BUSINESS PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

SUSPECT’S NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR APPROX. AGE

 

 

 

SEX

 

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

City

 

 

 

Zip

 

 

 

HOME PHONE

 

 

 

 

 

 

 

 

BUSINESS PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

OTHER RELEVANT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF NECESSARY, ATTACH EXTRA SHEET(S) OR OTHER FORM(S) AND CHECK THIS BOX

IF MULTIPLE VICTIMS, INDICATE NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE / TIME OF INCIDENT

 

 

PLACE OF INCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(What victim(s) said/what the mandated reporter observed/what person accompanying the victim(s) said/similar or past incidents involving the victim(s) or suspect)

SS 8572 (Rev. 12/02)DEFINITIONS AND INSTRUCTIONS ON REVERSE

DO NOT submit a copy of this form to the Department of Justice (DOJ). The investigating agency is required under Penal Code Section 11169 to submit to DOJ a Child Abuse Investigation Report Form SS 8583 if (1) an active investigation was conducted and (2) the incident was determined not to be unfounded.

WHITE COPY-Police or Sheriff’s Department; BLUE COPY-County Welfare or Probation Department; GREEN COPY-District Attorney’s Office; YELLOW COPY-Reporting Party

SS 8572 (12/02)

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SS 8572 (12/02)

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Complete the IN FOSTER CARE, IF VICTIM WAS IN OUTOFHOME CARE AT, TYPE OF ABUSE CHECK ONE OR MORE, PHYSICAL, MENTAL, YES, RELATIONSHIP TO SUSPECT, DAY CARE GROUP HOME OR INSTITUTION, CHILD CARE CENTER, FOSTER FAMILY HOME, FAMILY FRIEND, RELATIVES HOME, NEGLECT, OTHER SPECIFY, and S M T C V fields with any particulars that are asked by the software.

report cps form ca IN FOSTER CARE, IF VICTIM WAS IN OUTOFHOME CARE AT, TYPE OF ABUSE CHECK ONE OR MORE, PHYSICAL, MENTAL, YES, RELATIONSHIP TO SUSPECT, DAY CARE GROUP HOME OR INSTITUTION, CHILD CARE CENTER, FOSTER FAMILY HOME, FAMILY FRIEND, RELATIVES HOME, NEGLECT, OTHER SPECIFY, and S M T C V fields to fill out

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