My Program’s Reporting Procedures

Program Tool

WWW.VIRTUALLABSCHOOL.ORG

ACTIVITY ID: 14261

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 trainer, coach, or administrator.

I report my suspicions to:

Name
Telephone Number
Address (if applicable)

I provide the following information:

Child’s full name and age
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

I must follow these additional local reporting procedures:

My programs standard operating procedures and policies are located:

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