Child Abuse/Neglect Report Form

Your name *

Last name

Email address *

Confidential Report

This form is to be used for reporting concerns related to child abuse, neglect, or any other form of harm or danger to a child. Your information will be kept confidential and handled according to the legal requirements and safety protocols of this organization.

Phone number *

Phone type

Date of Report *

Relationship to Child (if any) *

Child Information

Name of Child *

Age of Child *

Gender *

Child’s Address (if known)

Name(s) of Parent/Guardian(s) *

Contact Information for Parent(s)/Guardian(s) (if known)

Details of the Incident

Type of Concern (Check all that apply)

Physical Abuse

Emotional Abuse

Neglect

Sexual Abuse

Domestic Violence

Verbal Abuse

Exploitation

Other

Date of Incident(s)

Input more dates

Location of Incident(s) *

Description of Incident(s) *

(Please provide as much detail as possible, including what happened, who was involved/witness, where it occurred, and any observed signs or injuries.)

Evidence (if applicable)

Are there any visible injuries or signs of abuse? *

Has medical attention been sought? *

Are there any witnesses to the incident(s)? *

Actions Taken

Have you reported this to any authorities or other organizations? *

Has anyone else been informed (e.g., school, counselor)? *

Reporter’s Signature

I certify that the information provided in this report is true and accurate to the best of my knowledge. *

Full name *

As typing your name you are electronically signing this document.

Date signed *

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First Baptist Church - Windom, MN
info@firstbaptistwindom.org
(507) 831-3811

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