Child Abuse Form Report Details

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.

QuestionAnswer
Form NameSs8572 Form Abuse
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesscar report, suspected child abuse report, mandated reporter form california, form ss 8572

Form Preview Example

- ATTACHMENT C -

SUSPECTEDCHILDABUSEREPORT

ToBeCompletedbyMandatedChildAbuseReporters

Pursuant to Penal Code Section 11166

PLEASE PRINT OR TYPE

CASENAME:

CASENUMBER:

A. REPORTING PARTY

NAME OF MANDATED REPORTER

 

 

TITLE

 

 

 

 

 

 

 

 

MANDATED REPORTER CATEGORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

Street

 

 

 

 

City

Zip

DID MANDATED REPORTER WITNESS THE INCIDENT?

 

 

 

 

REPORTER'S BUSINESS/AGENCY NAME AND ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

REPORTER'S TELEPHONE (DAYTIME)

SIGNATURE

 

 

 

 

 

 

 

 

 

TODAY'S DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REPORTB.

NOTIFICATION

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

 

 

 

 

 

 

 

reportOnepervictim

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

VICTIM.C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

DAY CARE CHILD CARE CENTER

FOSTER FAMILY

HOME

FAMILY FRIEND

 

PHYSICAL MENTAL

SEXUAL

NEGLECT

 

 

 

 

PRESENT LOCATION OF VICTIM

 

 

 

 

 

 

SCHOOL

 

 

CLASS

 

 

 

GRADE

 

 

 

 

PHYSICALLY DISABLED?

 

DEVELOPMENTALLY DISABLED?

 

OTHER DISABILITY (SPECIFY)

 

 

 

 

 

PRIMARY LANGUAGE

 

 

 

 

 

 

 

 

 

❘❒YES

NO

 

YES NO

 

 

 

 

 

 

 

 

 

 

 

 

SPOKEN IN HOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

 

 

 

 

NO

 

 

GROUP HOME OR INSTITUTION

RELATIVE'S HOME

 

 

 

 

 

 

OTHER (SPECIFY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RELATIONSHIP TO SUSPECT

 

 

 

 

 

 

PHOTOS TAKEN?

 

 

DID THE INCIDENT RESULT IN THIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

VICTIM'S DEATH?

YES

NO UNK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VICTIM'S

SIBLINGS

 

 

NAME

 

BIRTHDATE

 

 

SEX

ETHNICITY

 

 

 

 

 

 

NAME

 

 

BIRTHDATE

 

 

SEX

ETHNICITY

 

1.

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

PARTIESINVOLVED

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR APPROX. AGE

SEX

 

ETHNICITY

 

 

PARENTS/GUARDIANS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VICTIM'S

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

(

)

 

 

 

 

 

 

D.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUSPECT'S NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR APPROX. AGE

SEX

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUSPECT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

Street

 

 

City

 

 

 

 

Zip

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER RELEVANT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATIONINCIDENTE.

 

IFNECESSARY,ATTACHEXTRASHEET(S)OROTHERFORM(S)ANDCHECKTHISBOX

IFMULTIPLEVICTIMS,INDICATENUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE / TIME OF INCIDENT

PLACE OF INCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SS8572(Rev.12/02)

DEFINITIONS AND INSTRUCTIONS ON REVERSE

DONOTsubmitacopyofthisformtotheDepartmentofJustice(DOJ).TheinvestigatingagencyisrequiredunderPenalCodeSection11169tosubmittoDOJa ChildAbuseInvestigationReportFormSS8583if(1)anactiveinvestigationwasconductedand(2)theincidentwasdeterminednottobeunfounded.

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

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 11164-11174.3). A mandated reporter must complete and submit the form SS 8572 even if some of the requested information is not known. (PC Section 11167(a).)

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 yes-no box to indicate whether the victim may have a developmental disability or physical disability and specify any other apparent disability. Check the appropriate yes-no box to indicate whether the victim is in foster care, and check the appropriate box to indicate the type of care if the victim was in out-of-home care. Check the appropriate box to indicate the type of abuse. List the victim«s relationship to the suspect. Check the appropriate yes-no box to indicate whether photos of the injuries were taken. Check the appropriate box to indicate whether the incident resulted in the victim«s death.

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 yes-no whether the mandated reporter witnessed the incident. The signature area is for either the mandated reporter or, if the report is telephoned in by the mandated reporter, the person taking the telephoned report.

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

 

 

 

 

 

 

 

 

 

1

Alaskan Native

6

Caribbean

11

Guamanian

16

Korean

22 Polynesian

27

White-Armenian

2

American Indian

7

Central American

12

Hawaiian

17

Laotian

23 Samoan

28 White-Central American

3

Asian Indian

8

Chinese

13

Hispanic

18

Mexican

24 South American

29 White-European

4

Black

9

Ethiopian

14

Hmong

19

Other Asian

25 Vietnamese

30

White-Middle Eastern

5

Cambodian

10

Filipino

15

Japanese

21 Other Pacific Islander

26 White

31

White-Romanian