In today's society, there are many different types of abuse that people can experience. One type of abuse that is often overlooked is ss8572 form abuse. This type of abuse occurs when someone uses their position of authority to take advantage of someone else. Ss8572 form abuse can be very damaging to the victim and can leave them feeling helpless and alone. If you or someone you know is experiencing ss8572 form abuse, it is important to seek help immediately. There are many resources available to victims of ss8572 form abuse, and you don't have to face this situation alone.
You can find information regarding the type of form you want to complete in the table. It can tell you the amount of time you'll need to complete ss8572 form abuse, what fields you will need to fill in and some further specific facts.
Question | Answer |
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Form Name | Ss8572 Form Abuse |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | scar report, suspected child abuse report, mandated reporter form california, form ss 8572 |
- ATTACHMENT C -
SUSPECTEDCHILDABUSEREPORT
ToBeCompletedbyMandatedChildAbuseReporters
Pursuant to Penal Code Section 11166
PLEASE PRINT OR TYPE
CASENAME:
CASENUMBER:
A. REPORTING PARTY |
NAME OF MANDATED REPORTER |
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TITLE |
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MANDATED REPORTER CATEGORY |
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DID MANDATED REPORTER WITNESS THE INCIDENT? |
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REPORTER'S BUSINESS/AGENCY NAME AND ADDRESS |
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❒ YES |
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REPORTER'S TELEPHONE (DAYTIME) |
SIGNATURE |
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TODAY'S DATE |
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REPORTB. |
NOTIFICATION |
❒ LAW ENFORCEMENT |
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❒ COUNTY PROBATION |
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AGENCY |
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❒ COUNTY WELFARE / CPS (Child Protective Services) |
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ADDRESS |
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DATE/TIME OF PHONE CALL |
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OFFICIAL CONTACTED - TITLE |
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TELEPHONE |
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NAME (LAST, FIRST, MIDDLE) |
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BIRTHDATE OR APPROX. AGE |
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ETHNICITY |
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TELEPHONE |
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reportOnepervictim |
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VICTIM.C |
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❒ YES |
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❒ DAY CARE ❒ CHILD CARE CENTER |
❒ FOSTER FAMILY |
HOME |
❒ FAMILY FRIEND |
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❒ PHYSICAL ❒ MENTAL |
❒ SEXUAL |
❒ NEGLECT |
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PRESENT LOCATION OF VICTIM |
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SCHOOL |
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CLASS |
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GRADE |
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PHYSICALLY DISABLED? |
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DEVELOPMENTALLY DISABLED? |
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OTHER DISABILITY (SPECIFY) |
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PRIMARY LANGUAGE |
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❘❒YES |
❒ NO |
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❒ YES ❒ NO |
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SPOKEN IN HOME |
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IN FOSTER CARE? |
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IF VICTIM WAS IN |
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TYPE OF ABUSE (CHECK ONE OR MORE) |
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❒ NO |
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❒ GROUP HOME OR INSTITUTION |
❒ RELATIVE'S HOME |
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❒ OTHER (SPECIFY) |
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RELATIONSHIP TO SUSPECT |
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PHOTOS TAKEN? |
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DID THE INCIDENT RESULT IN THIS |
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❒ YES |
❒ NO |
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VICTIM'S DEATH? |
❒ YES |
❒ NO ❒ UNK |
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VICTIM'S |
SIBLINGS |
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NAME |
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BIRTHDATE |
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ETHNICITY |
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NAME |
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BIRTHDATE |
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SEX |
ETHNICITY |
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1. |
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3. |
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PARTIESINVOLVED |
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2. |
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NAME (LAST, FIRST, MIDDLE) |
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BIRTHDATE OR APPROX. AGE |
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ETHNICITY |
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PARENTS/GUARDIANS |
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VICTIM'S |
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HOME PHONE |
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BUSINESS PHONE |
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NAME (LAST, FIRST, MIDDLE) |
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BIRTHDATE OR APPROX. AGE |
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ETHNICITY |
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D. |
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SUSPECT'S NAME (LAST, FIRST, MIDDLE) |
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BIRTHDATE OR APPROX. AGE |
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ETHNICITY |
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SUSPECT |
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OTHER RELEVANT INFORMATION |
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INFORMATIONINCIDENTE. |
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IFNECESSARY,ATTACHEXTRASHEET(S)OROTHERFORM(S)ANDCHECKTHISBOX❒ |
IFMULTIPLEVICTIMS,INDICATENUMBER: |
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DATE / TIME OF INCIDENT |
PLACE OF INCIDENT |
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NARRATIVE DESCRIPTION (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) |
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SS8572(Rev.12/02)
DEFINITIONS AND INSTRUCTIONS ON REVERSE
DONOTsubmitacopyofthisformtotheDepartmentofJustice(DOJ).TheinvestigatingagencyisrequiredunderPenalCodeSection11169tosubmittoDOJa ChildAbuseInvestigationReportFormSS8583if(1)anactiveinvestigationwasconductedand(2)theincidentwasdeterminednottobeunfounded.
WHITE
DEFINITIONS AND GENERAL INSTRUCTIONS FOR COMPLETION OF FORM SS 8572
All Penal Code (PC) references are located in Article 2.5 of the PC. This article is known as the Child Abuse and Neglect Reporting Act (CANRA). The provisions of CANRA may be viewed at: http://www.leginfo.ca.gov/calaw.html (specify ƒPenal Code≈ and search for Sections
I.MANDATED CHILD ABUSE REPORTERS
•Mandated child abuse reporters include all those individuals and entities listed in PC Section 11165.7.
II.TO WHOM REPORTS ARE TO BE MADE (ƒDESIGNATED AGENCIES≈)
•Reports of suspected child abuse or neglect shall be made by mandated reporters to any police department or sheriff«s department (not including a school district police or security department), the county probation department (if designated by the county to receive mandated reports), or the county welfare department. (PC Section 11165.9.)
III. REPORTING RESPONSIBILITIES
•Any mandated reporter who has knowledge of or observes a child, in his or her professional capacity or within the scope of his or her employment, whom he or she knows or reasonably suspects has been the victim of child abuse or neglect shall report such suspected incident of abuse or neglect to a designated agency immediately or as soon as practically possible by telephone and shall prepare and send a written report thereof within 36 hours of receiving the information concerning the incident. (PC Section 11166(a).)
•No mandated reporter who reports a suspected incident of child abuse or neglect shall be held civilly or criminally liable for any report required or authorized by CANRA. Any other person reporting a known or suspected incident of child abuse or neglect shall not incur civil or criminal liability as a result of any report authorized by CANRA unless it can be proven the report was false and the person knew it was false or made the report with reckless disregard of its truth or falsity. (PC Section 11172(a).)
IV. INSTRUCTIONS (Continued)
•SECTION B - REPORT NOTIFICATION: Complete the name and address of the designated agency notified, the date/ time of the phone call, and the name, title, and telephone number of the official contacted.
•SECTION C - VICTIM (One Report per Victim): Enter the victim«s name, address, telephone number, birth date or approximate age, sex, ethnicity, present location, and, where applicable, enter the school, class (indicate the teacher«s name or room number), and grade. List the primary language spoken in the victim«s home. Check the appropriate
•SECTION D - INVOLVED PARTIES: Enter the requested
information for: Victim«s Siblings, Victim«s Parents/ Guardians, and Suspect. Attach extra sheet(s) if needed (provide the requested information for each individual on the attached sheet(s)).
•SECTION E - INCIDENT INFORMATION: If multiple victims, indicate the number and submit a form for each victim. Enter date/time and place of the incident. Provide a narrative of the incident. Attach extra sheet(s) if needed.
V. DISTRIBUTION
IV. INSTRUCTIONS
•SECTION A - REPORTING PARTY: Enter the mandated reporter«s name, title, category (from PC Section 11165.7), business/agency name and address, daytime telephone number, and today«s date. Check
•Reporting Party: After completing Form SS 8572, retain the yellow copy for your records and submit the top three copies to the designated agency.
•Designated Agency: Within 36 hours of receipt of Form SS 8572, send white copy to police or sheriff«s department, blue copy to county welfare or probation department, and green copy to district attorney«s office.
ETHNICITY CODES |
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1 |
Alaskan Native |
6 |
Caribbean |
11 |
Guamanian |
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Korean |
22 Polynesian |
27 |
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2 |
American Indian |
7 |
Central American |
12 |
Hawaiian |
17 |
Laotian |
23 Samoan |
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Asian Indian |
8 |
Chinese |
13 |
Hispanic |
18 |
Mexican |
24 South American |
29 |
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Black |
9 |
Ethiopian |
14 |
Hmong |
19 |
Other Asian |
25 Vietnamese |
30 |
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Cambodian |
10 |
Filipino |
15 |
Japanese |
21 Other Pacific Islander |
26 White |
31 |