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.

Use this template

Date

Time

Is the request regarding PHYSICAL ABUSE?

Physical abuse

Requested by

Nombre

Apellido

Agency

Case number

Case Number

Phone

Request Submitted by

Nombre

Apellido

Requestors' Email

Detective's Name (if not listed above)

Nombre

Apellido

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)

Nombre

Apellido

DFPS Worker's Email

DFPS case #

Child's Name

Nombre

Apellido

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

Nombre

Apellido

Gender

Male Female

Caregiver Language

Is this the caregiver that will bring child to appointment?

Yes No

Caregiver bringing child to appointment

Nombre

Apellido

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

Dirección

Ciudad

Estado / Provincia

Código postal

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

Nombre

Apellido

DOB or Age

Relationship to Child

Does SUS 1live in home of child?

Lives in the child's home

Name of Alleged Offender 2

Nombre

Apellido

DOB or Age

Relationship to Child

Does SUS 2live in home of child?

Lives in the child's home

Name of Alleged Offender 3

Nombre

Apellido

DOB or Age

Relationship to Child

Does SUS 3live in home of child?

Lives in the child's home

Child Abuse Report Form

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