Suspected Child Abuse Report Orange County Child Abuse Registry P.O.Box 14102, Orange, CA 92863-1502 To Be Completed by Mandated Child Abuse Reporters View Definitions & Instructions HERE (opens in new tab)CASE NAME: CASE NUMBER: A. Reporting PartyName of Mandated Reporter Title MANDATED REPORTER CATEGORY REPORTER’S BUSINESS/AGENCY NAME AND ADDRESS Street City Zip DID MANDATED REPORTER WITNESS THE INCIDENT? YES NO REPORTER’S TELEPHONE (DAYTIME)SIGNATURETODAY’S DATE Month Day Year B. REPORT NOTIFICATIONAGENCY TYPE LAW ENFORCEMENT COUNTY PROBATION COUNTY WELFARE / CPS (Child Protective Services) AGENCY ADDRESS Street City Zip DATE/TIME OF PHONE CALL Month Day Year OFFICIAL CONTACTED – TITLE TELEPHONEC. VICTIMOne report per victimNAME(LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX AGE SEX ETHNICITYView Ethnicity Codes Here – Opens in new tab ADDRESS Street City Zip TELEPHONEPRESENT LOCATION OF VICTIM SCHOOL CLASS GRADE PHYSICALLY DISABLED? YES NO DEVELOPMENTALLY DISABLED? YES NO OTHER DISABILITY (SPECIFY) PRIMARY LANGUAGE SPOKEN IN HOME IN FOSTER CARE? YES NO IF VICTIM WAS IN OUT-OF-HOME CARE AT TIME OF INCIDENT, CHECK TYPE OF CARE: DAY CARE CHILD CARE CENTER FOSTER FAMILY HOME FAMILY FRIEND GROUP HOME OR INSTITUTION RELATIVE’S HOME TYPE OF ABUSE (CHECK ONE OR MORE) PHYSICAL MENTAL SEXUAL NEGLECT OTHER (SPECIFY BELOW) OTHER TYPE OF ABUSE – SPECIFY RELATIONSHIP TO SUSPECT PHOTOS TAKEN? YES NO DID THE INCIDENT RESULT IN THIS VICTIM’S DEATH? YES NO UNK D. INVOLVED PARTIESVictim's SiblingsNAMEDATESEXETHNICITY Victim’s Parents/Guardians NAME(LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITYView Ethnicity Codes Here – Opens in new tab ADDRESS Street City Zip HOME PHONEBUSINESS PHONENAME(LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITYView Ethnicity Codes Here – Opens in new tab ADDRESS Street City Zip HOME PHONEBUSINESS PHONESUSPECTSUSPECT'S NAME(LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITYView Ethnicity Codes Here – Opens in new tab ADDRESS Street City Zip TELEPHONEOTHER RELEVANT INFORMATION E. INCIDENT INFORMATIONIF MULTIPLE VICTIMS, INDICATE NUMBER:DATE / TIME OF INCIDENT PLACE OF INCIDENT NARRATIVE DESCRIPTION(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)SignatureTODAY'S DATE Month Day Year View Definitions & Instructions HERE (opens in new tab) 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