Title: 
Headings:  SUSPECTED CHILD ABUSE REPORT
SUSPECTED
 
CHILD
 
ABUSE
 
REPORT
 

(Pursuant
 
to
 
Penal
 
Code
 
section
 
11166)

To
 
Be
 
Completed
 
by
 
Mandated
 
Child
 
Abuse
 
Reporters
 
CASE
 
NAME:

DEFINITIONS
 
AND
 
GENERAL
 
INSTRUCTIONS
 
FOR
 
COMPLETION
 
OF
 
FORM
 
BCIA
 
8572

I.
 
MANDATED
 
CHILD
 
ABUSE
 
REPORTERS
 

II.
 
TO
 
WHOM
 
REPORTS
 
ARE
 
TO
 
BE
 
MADE
 
("DESIGNATED
 
AGENCIES")
 

III.
 
REPORTING
 
RESPONSIBILITIES
 

IV.
 
INSTRUCTIONS
 

SECTION
 
B
 
–
 
REPORT
 
NOTIFICATION:
 
Complete
 
the
 

If
 
multiple
 
SECTION
 
E
 
–
 
INCIDENT
 
INFORMATION:
 

ETHNICITY
 
CODES


Content: YES
NO
DEVELOPMENTALLY
 
DISABLED? YES
NO
OTHER
 
DISABILITY
 
(SPECIFY)
 

OTHER
 
DISABILITY
 
(SPECIFY)
 

OTHER
 
DISABILITY
 
(SPECIFY)
 

OTHER
 
DISABILITY
 
(SPECIFY)
 

OTHER
 
DISABILITY
 
(SPECIFY)
 

OTHER
 
DISABILITY
 
(SPECIFY)
 

OTHER
 
DISABILITY
 
(SPECIFY)
 

PRIMARY
 
LANGUAGE
 
SPOKEN
 
IN
 
HOME

PRIMARY
 
LANGUAGE
 
SPOKEN
 
IN
 
HOME

PRIMARY
 
LANGUAGE
 
SPOKEN
 
IN
 
HOME


IN
 
FOSTER
 
CARE? YES
DAY
 
CARE
 
NO
FAMILY
 
FRIEND
IN
 
FOSTER
 
CARE? YES
DAY
 
CARE
 
NO
FAMILY
 
FRIEND
IF
 
VICTIM
 
WAS
 
IN
 
OUT-OF-HOME
 
CARE
 
AT
 
TIME
 
OF
 
INCIDENT,
 
CHECK
 
TYPE
 
OF
 
CARE: CHILD
 
CARE
 
CENTER
FOSTER
 
FAMILY
 
HOME
GROUP
 
HOME
 
OR
 
INSTITUTION
RELATIVE'S
 
HOME
IF
 
VICTIM
 
WAS
 
IN
 
OUT-OF-HOME
 
CARE
 
AT
 
TIME
 
OF
 
INCIDENT,
 
CHECK
 
TYPE
 
OF
 
CARE: CHILD
 
CARE
 
CENTER
FOSTER
 
FAMILY
 
HOME
GROUP
 
HOME
 
OR
 
INSTITUTION
RELATIVE'S
 
HOME
IF
 
VICTIM
 
WAS
 
IN
 
OUT-OF-HOME
 
CARE
 
AT
 
TIME
 
OF
 
INCIDENT,
 
CHECK
 
TYPE
 
OF
 
CARE: CHILD
 
CARE
 
CENTER
FOSTER
 
FAMILY
 
HOME
GROUP
 
HOME
 
OR
 
INSTITUTION
RELATIVE'S
 
HOME
IF
 
VICTIM
 
WAS
 
IN
 
OUT-OF-HOME
 
CARE
 
AT
 
TIME
 
OF
 
INCIDENT,
 
CHECK
 
TYPE
 
OF
 
CARE: CHILD
 
CARE
 
CENTER
FOSTER
 
FAMILY
 
HOME
GROUP
 
HOME
 
OR
 
INSTITUTION
RELATIVE'S
 
HOME
IF
 
VICTIM
 
WAS
 
IN
 
OUT-OF-HOME
 
CARE
 
AT
 
TIME
 
OF
 
INCIDENT,
 
CHECK
 
TYPE
 
OF
 
CARE: CHILD
 
CARE
 
CENTER
FOSTER
 
FAMILY
 
HOME
GROUP
 
HOME
 
OR
 
INSTITUTION
RELATIVE'S
 
HOME
IF
 
VICTIM
 
WAS
 
IN
 
OUT-OF-HOME
 
CARE
 
AT
 
TIME
 
OF
 
INCIDENT,
 
CHECK
 
TYPE
 
OF
 
CARE: CHILD
 
CARE
 
CENTER
FOSTER
 
FAMILY
 
HOME
GROUP
 
HOME
 
OR
 
INSTITUTION
RELATIVE'S
 
HOME
IF
 
VICTIM
 
WAS
 
IN
 
OUT-OF-HOME
 
CARE
 
AT
 
TIME
 
OF
 
INCIDENT,
 
CHECK
 
TYPE
 
OF
 
CARE: