* Indicates REQUIRED information. Enter N/A for unknown information.

REPORTER INFORMATION

This information is required for professionally mandated reporters per Florida Statute 39.201 (1)(d)(1-7).

 

      

      




 




 


 

     

     

     


(If reporting as a professional)
 

     


VICTIM LOCATION INFORMATION


 


 

    

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*  


 





INFORMATION ON CHILDREN

In this section please list all known victims as well as other non-victim children residing in the home.

# First Name Last Name DOB/Age * Sex Race SSN Is This Person a Victim?*
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INFORMATION ON ADULTS

In this section please list all alleged perpetrators as well as other adults residing in the home.

# First Name Last Name DOB/Age Sex Race SSN Relationship to Victim
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9






10







DESCRIPTION OF INCIDENT *

Please describe the following if known: WHAT happened, WHO'S involved, WHEN and WHERE did the incident occur, impacts/effects on the victims, a description of injuries and/or threat of harm, the frequency of occurrence, and the history of occurrences.



ADDITIONAL FAMILY DYNAMIC INFORMATION (If known)

If known, please provide any information known that describes normal day to day behaviors and activities of the victim, alleged perpetrator, or any person identified as residing in the home.
Also, how would you describe the typical interactions between the children and adults?
Can you describe normal disciplinary practices in the home?



DISABILITIES

Please identify if any child or adult listed has any disabilities, hearing impairments, or limited English proficiencies.
If hearing impairments are known, how does the individual communicate?
Does the individual utilize any devices to assist with communication?



OTHER INDIVIDUALS

Please list other individuals who might be aware of the abuse, abandonment, neglect, or exploitation of the victim.

# First Name Last Name Relationship to Victim Address Home Phone Work Phone
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