Directions: Complete each section of this form so that you know the specific reporting procedures for your program. Please review your responses with your trainer, coach, or administrator.

I report my suspicions to:

I provide the following information:

• Child’s full name and age
• Parent or guardian’s name and address
• Reasons for suspected abuse or neglect
• Description and location of injuries (if applicable)
• Information freely disclosed by victim
• Current location of victim
• Known information regarding incident or chronology of events

I must follow these additional local reporting procedures: 

My programs standard operating procedures and policies are located: