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REPORT OF CHILD(REN) ALLEGED
TO BE
SUFFERING
FROM SERIOUS PHYSICAL OR EMOTIONAL INJURY BY ABUSE OR NEGLECT
What is the nature and extent of
the
injury,
abuse, maltreatment or neglect, including evidence of same?
(Please
cite the source of this information if not observed first hand.)
What are the circumstances under
which
the
reporter became aware of the injuries, abuse, maltreatment or neglect?
What action has been taken thus
far to
treat,
shelter, or otherwise assist the child to deal with the situation?
Please give other information
which you
think
might be helpful in establishing the cause of the injury and/or the
person
responsible for it. If known, please provide the name(s) of the
perpetrator(s).
_______________________________
Signature
of Reporter
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