My Program's Reporting Procedures

Program Tool

WWW.VIRTUALLABSCHOOL.ORG

ACTIVITY ID: 23876

Name

Certifier

Date

Directions: Complete each section of this form so that you know the specific reporting procedures for your program. Please review your responses with your coach, trainer, or administrator.

I report my suspicions to:

Name
Telephone Number
Address (if applicable)

I provide the following information:

Child's first name and last name
Parent or guardian's name and address
Reasons for suspected abuse or neglect
Description and location of injuries (if applicable)
Information freely disclosed by victim
Current location of victim
Known information regarding incident or chronology of events

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I report my suspicions to:

I provide the following information:

My program's standard operating procedures and policies are located:

I must follow these additional local reporting procedures:

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I report my suspicions to:

I provide the following information:

My program's standard operating procedures and policies are located:

I must follow these additional local reporting procedures:

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