Form: Report Harm of Child

All staff and child care workers are responsible to report any disclosures or possible evidence of harm to a child. These reports must be submitted to the Child Protection Response Team (CPRT) at [email protected] within 24 hours of filling out the known data. The report should be submitted using this form, which can also be accessed online at Cadence.org/ReportHarm. Please report only the information that is known at the time the allegation was received without interviewing the child(ren) harmed or alleged perpetrator(s). Not all blanks need to be filled in order to submit this form. The CPRT will be in contact with you and appropriate staff to guide the response. If you have not received acknowledgement from a CPRT member within 36 hours, please resubmit.

Person Making Report (The person with information pertaining to the incident)

Name

First Last

Position

Report Date

Report Time

: HH

MM

Relationship to child(ren) harmed

Email

Phone

Has this incident been reported to a government, law enforcement, or child protective service agency? (If so, list agency name, name of person to whom report was given, agency contact information, case reference number, etc.)

Child Harmed

Name

First Last

Select one

Male
Female

Age / Date of Birth

Grade

Father's Name

Father's Phone

Father's Email

Mother's Name

Mother's Phone

Mother's Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Names and Ages of other Siblings

Alleged Perpetrator

Name

First Last

Select one

Male
Female

Age

Grade / Job

Guardian Name(s) (if applicable)

Relationship to child harmed

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Incident Report

How was the information obtained or observed?

Was the reported information volunteered? What prompted the report? Was there suspicion of harm? What led to the suspicion of harm/abuse/neglect/inappropriate behavior? Who was present for the report?

Details of what was reported or suspected

Include: Dates, Frequency, Places. What happened? (Quote exactly the words spoken as much as possible.)

Who else knows about the alleged harm?

List names, relationship to child harmed, and phone.

Who else might be affected by or involved in the harmful actions and/or behaviors?

Classmates, siblings, friends, adults, others present at the same event, etc.

Things done to protect child harmed

Such as contact government, law enforcement, or child protective service agencies, create safety plan, etc.

Person Filing Report (If different from the person making the report)

Name

First Last

Position

Email

Phone