Report Suspected Child Abuse or Neglect

Person Making Report (Name):

Role at the University

If you answered, "Other" to the question above, please enter your role:

With what School or Division are you affiliated?

If you answered "Other," please enter your University affiliation:

University phone number, if you have one:

Nature of Report:

To the extent of your knowledge, please provide the following information about the child.

Full name of child:

Sex:

Male

Female

Age:

Child's date of birth:

Address of child:

To the extent of your knowledge, please provide the following information about the suspected abuser.

Name:

Relationship to Child:

Relationship, if any, to UMB:

Other information to locate the suspected abuser:

Do you have information regarding the child’s parent or other care-giver?

If you answered "Yes" to the question above, please provide information about the child's parent or other person responsible for the child's care.

Name:

Address:

Telephone number:

Relationship to child:

Please describe the abuse or neglect to the child.

Description of nature and extent of suspected abuse, neglect or mental injury:

Reason to believe that the child is a victim, including your source of information:

To the extent you are aware, please supply the following information about the child's household.

Information about past abuse of the child or other children in the family:

Other information about family function or relationships:

Weapons possessed by the suspected abuser or other potential for violence:

Have you contacted Child Protective Services or your local police department about your concerns?

Yes

If you answered "Yes," to the question directly above, please answer the following six questions.

Name of agency or police department:

Location of agency or department:

Telephone number:

Date when called:

Time when called:

Person to whom oral report was made:

Do you have information regarding the child’s parent or other care-giver?

Possible need for child's referral for counseling, health care or other services:

Any concerns that the victim may experience negative consequences as a result of this report and its investigation:

Other concerns regarding suspected abuse, neglect, mental injury or child's needs:

Print this page before clicking the “Submit” button below, if you would like a hard copy of your report.