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File Name___________


To be used by a person who suspects abuse but didn’t actually see it happen.
Reasons reporting could include physical signs or a statement from the child or another person.
(Please use a computer, type, or print all information.)

Date of this report: Submitted to:

Name of reporter: Signature:
Contact information:

Date/Time/Location of incident:

Statement of what occurred. Cite every detail you can remember and use direct quotations
wherever possible. CAUTION: Do not question a child for more information than they volunteer.
Leave that for trained officials.

Name of child/youth involved: Age:

Contact information of child/youth:
Parent or guardian:
Contact information of parent or guardian

On the back of this sheet, list names, parents (where applicable) and contact information of
all persons involved.

This is a sample form. It needs to be modified to meet the specific needs of your congregation. For information
about creating policies and procedures for the safety of children and youth, please see Safe Sanctuaries, Safe
Sanctuaries for Youth, or Santuarios Seguros published by Discipleship Resources.

© 2006 The General Board of Discipleship of the United Methodist Church

Permission is given to reproduce this form for churches who have purchased Safe Sanctuaries.