Suspected Child Abuse Report Form

This form should be filled out any time there is suspicion or an allegation of abuse of a child at Grace Church; this includes any child participating in programming at Grace Church whether he or she is the child of a member or a one-time visitor. This form should be filled out by the person who suspects or witnessed possible abuse or received a disclosure of abuse from a child. All of the information on this form should be kept confidential. For our purposes, this form will define "child" as anyone under 18. Pastor Eric as well as Abigail Cajiga (Children's Ministry) or Daniel Schwab (Youth Ministry) should also be contacted any time this form is filled out.

Your name *

Email address *

Victim's Name and Age: *

Victim's Parent/Guardian, if applicable: *

Victim/Guardian's Phone Number and Email: *

Is the suspected perpetrator known? If so, provide his or her name and age. If not, provide a description. *

Suspected Perpetrator's Phone Number and Email, if known: *

Location of Suspected Abuse (be as specific as you can): *

Reason for Report/Details of Incident (be as descriptive as you can): *

Please list any witnesses here, including their contact information: *

Please list any Grace Church leadership or staff you have personally informed of this report: *

Were state or local authorities notified of suspected abuse? If so, please list which agency and any details of who was contacted (i.e. phone numbers, case number, person spoken to). *

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