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The SS8572 Abuse form serves as a critical tool for mandated child abuse reporters in the United States, as it facilitates the documentation and reporting of suspected child abuse cases. Designed to gather comprehensive information, the form requires details about the victim, including their name, age, ethnicity, and contact information, as well as specifics about the incident, such as date, time, and location. It also collects information about the suspected abuser and any witnesses present. To ensure each report is as informative as possible, each section of the form is clearly delineated, allowing reporters to specify the type of abuse involved—whether physical, mental, sexual, or neglect. Importantly, the form mandates that each submission pertains to a single victim to maintain clarity and focus in the investigation process. The SS8572 not only aids in immediate reporting but also ensures that pertinent data is gathered for follow-up investigations by law enforcement, child protective services, and other relevant agencies. As delineated under various legal statutes, the information collected on this form is instrumental in protecting the welfare of children and initiating appropriate interventions.

Ss8572 Abuse Example

NARRATIVE DESCRIPTION

SUSPECTED CHILD ABUSE REPORT

To Be Completed by Mandated Child Abuse Reporters

 

Pursuant to Penal Code Section 11166

CASE NAME:

PLEASE PRINT OR TYPE

CASE NUMBER:

REPORTING

PARTY

A.

 

B. REPORT

NOTIFICATION

One Report Per Victim

C. VICTIM

 

VICTIMS SIBLINGS

INVOLVED PARTIES

VICTIM’S PARENTS/GUARDIANS

D.

 

 

SUSPECT

E. INCIDENT INFORMATION

 

NAME OF MANDATED REPORTER

 

 

 

TITLE

 

 

 

 

 

 

 

 

 

 

MANDATED REPORTER CATEGORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DID MANDATED REPORTER WITNESS THE

REPORTER’S BUSINESS/AGENCY NAME AND ADDRESS

 

 

Street

 

 

 

 

 

City

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCIDENT?

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TODAY’S DATE

 

 

 

 

 

 

 

 

REPORTER’S TELEPHONE (DAYTIME)

 

 

SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAW ENFORCEMENT

COUNTY PROBATION

AGENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY WELFARE / CPS (Child Protective Services)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

 

 

City

 

 

 

 

 

 

 

 

Zip

 

 

 

 

DATE/TIME OF PHONE CALL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICIAL CONTACTED – TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR

 

APPROX. AGE

 

 

SEX

 

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

 

 

City

 

 

 

 

 

 

 

 

Zip

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESENT LOCATION OF VICTIM

 

 

 

 

 

 

SCHOOL

 

 

 

 

 

 

 

 

 

 

CLASS

 

 

 

 

 

 

GRADE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICALLY DISABLED?

DEVELOPMENTALLY DISABLED?

 

 

OTHER DISABILITY (SPECIFY)

 

 

 

 

PRIMARY LANGUAGE SPOKEN IN HOME

 

YES

NO

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IN FOSTER CARE?

IF VICTIM WAS IN OUT-OF-HOME CARE AT TIME OF INCIDENT, CHECK TYPE OF CARE:

 

 

TYPE OF ABUSE (CHECK ONE OR MORE)

 

YES

 

DAY CARE

 

 

CHILD CARE CENTER

FOSTER FAMILY HOME

FAMILY FRIEND

 

PHYSICAL

 

 

MENTAL

 

SEXUAL

 

 

 

 

 

NEGLECT

 

 

 

 

 

 

 

 

 

NO

 

GROUP HOME OR INSTITUTION

RELATIVE’S HOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER (SPECIFY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RELATIONSHIP TO SUSPECT

 

 

 

 

 

 

 

 

 

 

 

 

 

PHOTO’S TAKEN?

 

 

DID THE INCIDENT RESULT IN THIS VICTIM’S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

DEATH? YES

 

NO

 

 

 

UNK

1.

 

 

NAME

BIRTHDATE

SEX

ETHNICITY

 

3.

 

 

 

 

NAME

 

 

 

BIRTHDATE

 

 

SEX

 

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR APPROX. AGE

 

 

SEX

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

City

 

 

 

Zip

 

 

 

HOME PHONE

 

 

 

 

 

 

 

 

BUSINESS PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR APPROX. AGE

 

 

 

SEX

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

City

 

 

 

Zip

 

 

 

HOME PHONE

 

 

 

 

 

 

 

 

BUSINESS PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

SUSPECT’S NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE OR APPROX. AGE

 

 

 

SEX

 

 

ETHNICITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

Street

 

 

 

City

 

 

 

Zip

 

 

 

HOME PHONE

 

 

 

 

 

 

 

 

BUSINESS PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

OTHER RELEVANT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF NECESSARY, ATTACH EXTRA SHEET(S) OR OTHER FORM(S) AND CHECK THIS BOX

IF MULTIPLE VICTIMS, INDICATE NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE / TIME OF INCIDENT

 

 

PLACE OF INCIDENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(What victim(s) said/what the mandated reporter observed/what person accompanying the victim(s) said/similar or past incidents involving the victim(s) or suspect)

SS 8572 (Rev. 12/02)DEFINITIONS AND INSTRUCTIONS ON REVERSE

DO NOT submit a copy of this form to the Department of Justice (DOJ). The investigating agency is required under Penal Code Section 11169 to submit to DOJ a Child Abuse Investigation Report Form SS 8583 if (1) an active investigation was conducted and (2) the incident was determined not to be unfounded.

WHITE COPY-Police or Sheriff’s Department; BLUE COPY-County Welfare or Probation Department; GREEN COPY-District Attorney’s Office; YELLOW COPY-Reporting Party

SS 8572 (12/02)

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Clear Form

Print Form

SS 8572 (12/02)

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Get Ss8572 Abuse PDF Form

Form Characteristics

Fact Name Description
Purpose The SS8572 form is designed to report suspected child abuse and must be completed by mandated reporters.
Governing Law This form adheres to California Penal Code Section 11166, which outlines the requirements for reporting child abuse.
Who Completes It Only mandated child abuse reporters, such as teachers, social workers, and healthcare providers, are authorized to fill out this form.
Victim Details The form requires detailed information about the victim, including name, age, sex, and ethnicity.
Incident Information Reports must include information on the type of abuse, location, and any relevant details about what the victim or witnesses observed.
Submission Process The completed form should not be submitted to the Department of Justice but rather to the appropriate local agency for further investigation.
Outcome Reporting If an investigation occurs and the incident is found to be valid, a separate report (SS 8583) must be submitted to the DOJ.
Copy Distribution Different copies of the form are designated for specific agencies: Police, County Welfare, District Attorney, and Reporting Party.

Guidelines on Utilizing Ss8572 Abuse

Filling out the SS8572 form is a critical step in the reporting process for suspected child abuse. This form needs to be completed accurately and promptly to ensure that the appropriate authorities are notified. Once you have the form filled out, it should be submitted to the designated agency for further investigation. Here are the steps to follow when completing the SS8572 Abuse form:

  1. Begin by writing the Case Name at the top of the form. Make sure it is printed clearly.
  2. Next, enter the Case Number in the specified area.
  3. Identify yourself as the Reporting Party by providing your name and relevant details. Include your title and the agency you represent.
  4. Complete the REPORT NOTIFICATION section by indicating if this report is for one victim or multiple victims.
  5. Fill in the details of the Victim, including their name, age, sex, ethnicity, address, and primary language spoken in the home.
  6. Next, list any Victim's Siblings involved and provide their details as necessary.
  7. Identify the Suspect by filling in their name, age, sex, ethnicity, and address.
  8. Document the Incident Information, including the date, time, and place of the incident. Provide a description of what the victim said, what the reporter observed, or any other relevant details.
  9. Indicate if there were any Photos Taken related to the incident and if it resulted in the victim’s death.
  10. Provide any Other Relevant Information that needs to be included on the form, attaching extra sheets if necessary.
  11. Sign and date the form, and provide your telephone number in the designated area.
  12. Once completed, ensure to keep a copy for your records before sending the appropriate copies to the respective agencies: police, welfare, or district attorney's office.

What You Should Know About This Form

What is the SS8572 Abuse form?

The SS8572 Abuse form is used to report suspected child abuse in California. It must be filled out by mandated reporters, such as teachers, doctors, and social workers. The form collects information about the victim, the suspected abuser, and details regarding the incident.

Who is required to fill out this form?

Mandated reporters, individuals legally obligated to report suspected child abuse, are responsible for completing the SS8572 form. This includes professionals like teachers, healthcare providers, and law enforcement officers.

What information must be included in the form?

The form requires detailed information about the case, including the victim’s name, age, and address. It also asks for details about the suspected abuser, the nature of the abuse, and any observations made by the reporter. If multiple victims are involved, the form can accommodate that as well.

Can I submit a copy of this form to the Department of Justice?

No, you must not submit a copy of the SS8572 form to the Department of Justice. Instead, the investigating agency will submit a different form, SS 8583, under specific conditions outlined by law.

What should I do if I witness an incident of abuse?

If you witness an incident of child abuse or suspect that it is happening, you should fill out the SS8572 form as soon as possible. Follow your reporting obligations and submit the form to the appropriate agency, such as the police department or child protective services.

What does "mandated reporter witnessed the incident" mean?

This question addresses whether the reporter directly observed the incident of abuse. If they did, they indicate "Yes" on the form. If they only heard about it or learned about it in another way, they would answer "No." This distinction can impact the investigation process.

What happens after I submit the form?

Once you submit the SS8572 form, the investigating agency will review the information you provided. They will decide whether further investigation is necessary. Your report helps ensure that appropriate actions are taken to protect the child involved.

Is the information on the SS8572 Abuse form confidential?

Yes, information submitted on the SS8572 form is treated as confidential. However, mandated reporters may be required to testify in court if the case goes to trial. It is important to ensure that your report is accurate and truthful.

What if I am unsure whether something qualifies as abuse?

If you suspect a child is being abused but are unsure, it is better to report your concerns. The investigating agency will evaluate the situation further. You are encouraged to report any suspicions rather than risk the well-being of a child.

Where can I get more information about child abuse reporting?

For more information, you can contact local child protective services, law enforcement, or visit the California Department of Social Services website. They can provide resources and guidance on recognizing and reporting child abuse.

Common mistakes

When completing the SS8572 Abuse form, one common mistake is failing to provide complete and accurate contact information for the victim and suspect. It’s essential that each section of the form, especially names and addresses, is filled out clearly. Incomplete or incorrect information can delay the investigation and create additional challenges for those involved.

Another mistake is not adequately describing the incident. The narrative section should detail what was observed or reported by the mandated reporter. Vague statements or insufficient details can hinder the ability of authorities to take appropriate action. Including specifics about the date, time, and location of the incident allows for a better understanding of the circumstances.

Omitting to check all relevant boxes regarding the type of abuse is another error. There can be various forms of abuse, including physical, mental, or sexual. Even if only one type is suspected, checking multiple boxes provides a fuller picture of the situation. This thoroughness is crucial for a comprehensive investigation, so it is important to take the time to consider all possibilities.

Lastly, not signing the form or forgetting to include the date is a critical oversight. The signature serves as verification that the information provided is accurate and that the reporter is formally submitting the report. A missing signature or date could render the form incomplete and necessitate resubmission. Always double-check that every requirement is met before submitting the form.

Documents used along the form

When dealing with suspected child abuse, several forms and documents accompany the SS8572 Abuse form to ensure a thorough response and documentation of the situation. These documents facilitate communication between various agencies and provide crucial details for investigations. Below is a list of commonly used forms and documents alongside the SS8572 Abuse form.

  • Child Abuse Investigation Report Form SS 8583: This form is submitted by the investigating agency when an active investigation is conducted. It includes details about the incident, findings, and actions taken.
  • Mandated Reporter Training Certificate: This document confirms that a person has completed training on recognizing and reporting child abuse, which is a requirement for certain professionals, such as teachers and social workers.
  • Family Assessment Referral Form: Used by Child Protective Services (CPS) to gather information about the family's needs and circumstances during the assessment process following a report.
  • Incident Report: A detailed account created by law enforcement or the reporting party documenting the specific events surrounding the suspected abuse, including interviews and observations made.
  • Health Evaluation Form: This form collects medical information about the child, which can provide evidence of physical or psychological harm related to the reported abuse.
  • Safety Plan: Developed to protect the child and outline steps to ensure their safety while investigations proceed. It may involve temporary custody changes or other measures.
  • Child Welfare Case Plan: This document outlines the services and interventions provided to the family to address the factors that led to abuse and ensure the child’s safety and well-being.
  • Referral for Counseling Services: When the child or family requires emotional support, this document refers them to mental health services to help cope with the trauma experienced.
  • Letter of Notification: This is typically sent to the victim’s guardians informing them that a report has been made and providing them with information on potential next steps.
  • Confidentiality Agreement: This document ensures that involved parties understand their obligations to keep information related to the abuse case private, protecting the victim's rights and dignity.

These forms play critical roles in creating a cohesive response to instances of suspected child abuse. By utilizing them, relevant parties work together to provide the best care and support for victims while maintaining a detailed record of actions taken. Each document serves a purpose, allowing for collaborative efforts to protect children and foster thorough investigations.

Similar forms

  • Child Abuse Investigation Report (SS 8583): This form is similar as it also addresses cases of suspected child abuse. However, it is specifically used to summarize the findings of an investigation conducted by law enforcement or child protective services.

  • Mandatory Reporting Form: Like the SS8572, this document is completed by mandated reporters. It captures information about suspected abuse but may vary slightly in format and may not be specifically tailored for child abuse cases.

  • Victim Impact Statement: This document shares details regarding the effects of a crime on the victim. Similar to the SS8572, it prioritizes the victim’s voice but focuses on presenting the repercussions rather than solely reporting an incident.

  • Incident Report Form: This generic document collects data pertaining to various incidents. It is similar in that it contains descriptive information about events but does not specifically focus on child abuse.

  • Law Enforcement Statement: This report is prepared by law enforcement after an incident. While it may overlap with the SS8572 in terms of reporting facts, it often emphasizes conclusions and legal actions taken.

  • Safety Assessment Form: This tool evaluates a child’s immediate safety. It shares the objective of assessing risk like the SS8572 but engages more in evaluating the environment surrounding the victim.

  • Child Protective Service Referral Form: This document initiates services for a child in need. Similar to the SS8572, it reports on child welfare concerns but often works within broader service provision frameworks.

  • Foster Care Placement Review:** This document assesses a child's foster placement. While its focus is different, it emphasizes the needs and protection of the child, paralleling the intentions of the SS8572.

Dos and Don'ts

When completing the SS8572 Abuse form, it is important to follow certain guidelines to ensure that you provide accurate and effective information. Below is a list of things you should and shouldn't do while filling out the form.

  • Do carefully read all instructions before starting to fill out the form.
  • Do provide complete and truthful descriptions of the incident based on your observations.
  • Do include all relevant contacts and information about the victim, family, and incident.
  • Do keep a copy of the form for your records after submitting it to the appropriate agency.
  • Do report any immediate danger to the victim to law enforcement right away.
  • Don't use vague or unclear language; be specific in your descriptions.
  • Don't include personal opinions or judgments about the parties involved.
  • Don't forget to check all appropriate boxes regarding the type of abuse and care.
  • Don't submit a copy of the form to the Department of Justice.
  • Don't delay in reporting if there is an immediate risk to the victim's safety.

Misconceptions

Misconceptions about the SS8572 Abuse form can lead to confusion and improper reporting practices. Here are some common misunderstandings:

  1. Only Professionals Can Report Abuse: While mandated reporters include professionals who work with children, anyone who suspects child abuse can report it. It is a civic duty to ensure the safety of a child.
  2. One Report Per Incident: Many believe that only one report can be filed for each incident. In reality, each victim requires a separate report, regardless of whether the cases are related.
  3. Witnessing Abuse Is Mandatory: Some think that a mandated reporter must witness the abuse to make a report. If there is reasonable suspicion, even without direct observation, a report can still be made.
  4. All Forms of Abuse Must Be Reported Together: Many people think that all types of abuse must be included in one report. However, multiple forms of abuse can be reported separately if they pertain to different incidents or victims.
  5. The Report Must Be Perfectly Detailed: There is a misconception that reports must be exhaustive and flawless. The main requirement is to provide enough information to allow investigators to take appropriate action.
  6. Submitting Copies to Other Agencies: Some believe they must send copies of the form to outside agencies. In fact, the reporting party does not submit the form to the Department of Justice; that is the responsibility of the investigating agency.
  7. Age of Victim Does Not Matter: It's often thought that the age of the victim is irrelevant when reporting. However, the age is crucial, as different ages may dictate different responses and resources.
  8. Anonymous Reports Are Not Possible: Many individuals think they cannot file a report anonymously. In California, individuals can report suspicions of child abuse without revealing their identity.
  9. Reporting Is Optional: A misunderstanding exists that reporting suspected abuse is optional. In fact, mandated reporters are legally required to make reports, failing which can lead to penalties.

Key takeaways

When completing and using the SS8572 Abuse form, keep these key points in mind.

  • One Report Per Victim: Ensure that each victim involved has a separate report. This helps maintain clarity and ensures that all necessary details are addressed.
  • Accurate Information: Fill out all sections carefully, including names, dates, and addresses. Inaccurate information can delay necessary actions.
  • Mandated Reporter: Identify yourself as a mandated reporter and provide your title. This establishes your obligation to report suspected abuse.
  • Incident Description: Provide a detailed narrative of what occurred. Include observations and statements made by the victim or others present during the incident.
  • Important Notifications: Be aware that you should not submit a copy of this form to the Department of Justice. Follow the correct procedures for reporting.
  • Multiple Victims: If there are multiple victims, indicate the number clearly. Use extra sheets if necessary and check the appropriate box on the form.

Completing this form accurately is crucial for the protection and support of victims. Take your time to ensure everything is correct before submission.

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