Trinity Presbyterian
Suspected Abuse Incident Report Form
Completing this Suspected Abuse Incident Form will assist Trinity’s Response Team in responding to the concern or allegation. All information on this form will be provided on a confidential basis to the appropriate law enforcement agency. It is imperative that the person taking action with the information in this report be familiar with the state and local law reporting requirements.
The term "Protected Individual" refers to all minors age birth to 18 years of age protected under Trinity’s Child And Youth Abuse Prevention Policy.
Name of person observing or receiving disclosure of child abuse (Reporter):
Street Address of Reporter:
City: State: Zip Code:
Phone Number of Reporter:
Date of Incident: Time of Incident:
Location of Incident:
Name(s) of Minor(s): Minor's Age:
Name(s) of those suspected of abuse or causing neglect:
Relationship of the accused to the minor:
Date/Place of initial conversation with/report from minor:
Minor's statement (quote relevant statements made by the minor):
Describe the minor's demeanor and/or appearance:
What immediate action was taken:
Does anyone else have relevant information? Were there any witnesses?
NAME PHONE NUMBER
Report Submitted to (Response Team Member):
Reporter's Signature: Date:
Response Team’s Record of Reports of Incident of Suspected Abuse:
Reported to Senior/Executive Pastor : _________________________________ Date/Time:
Summary:
By whom: Signature:
Report to minor's parent/guardian: _________________________________ Date/Time:
Summary:
By whom: Signature:
Report to DFCS: Date/Time:
Summary:
By whom: Signature:
Report to Law Enforcement Agency: Date/Time:
Summary:
By whom: Signature:
Other Contacts: Date/Time:
Summary:
By whom: Signature:
Other Contacts: Date/Time:
Summary:
By whom: Signature: