Child Abuse Report Form

A structured intake used by caseworkers and investigators to document a suspected child abuse case, covering the child, caregiver, and alleged offender details.

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In the Claude connectors directory

Date

Time

Is the request regarding PHYSICAL ABUSE?

Physical abuse

Requested by

First Name

Last Name

Agency

Case number

Case Number

Phone

Request Submitted by

First Name

Last Name

Requestors' Email

Detective's Name (if not listed above)

First Name

Last Name

Badge Number (if known)

Detective's Email

Law Enforcement Offense # (if not listed above)

LE only case

Yes No

DFPS Worker's Name (if not listed above)

First Name

Last Name

DFPS Worker's Email

DFPS case #

Child's Name

First Name

Last Name

Child's DOB

gender

Male Female

Child's Language

Does the child have any medical needs?

Does the child have any developmental needs?

Child lives with (name and relationship):

Child's Caregiver

First Name

Last Name

Gender

Male Female

Caregiver Language

Is this the caregiver that will bring child to appointment?

Yes No

Caregiver bringing child to appointment

First Name

Last Name

Relationship of this caregiver

Caregiver transporting child to appointment phone number

Does the caregiver know the child has been referred to CARE?

Yes No

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Alternate Phone Number

E-mail

Type of abuse concerns

Physical Sexual Emotional Neglect

To child

Applies to the child

To alleged offender

Applies to the alleged offender

PHAB Concern

Drug Exposure Concern

One Time Incident

Yes No

Date of First Incident (as best as can report)

Date of Last Incident

Duration/Frequency

Last Incident (if unknown ONLY)

Less than a week ago 1-4 weeks ago 1-6 months ago More than 6 months ago

Brief description of child's outcry (If needed):

Name of Alleged Offender 1

First Name

Last Name

DOB or Age

Relationship to Child

Does SUS 1live in home of child?

Lives in the child's home

Name of Alleged Offender 2

First Name

Last Name

DOB or Age

Relationship to Child

Does SUS 2live in home of child?

Lives in the child's home

Name of Alleged Offender 3

First Name

Last Name

DOB or Age

Relationship to Child

Does SUS 3live in home of child?

Lives in the child's home

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