Incident Report of Suspected Child or Youth Abuse Form
Note: For your privacy, this form will be sent directly to our Pastor's e-mail upon submission.

1.	Name of worker (paid or volunteer) disclosing incident of suspected abuse of a child or youth:*
	Date/time of the incident report:*
	Location of the incident:*
2.	Name of alleged victim:*
	Age/Date of birth of alleged victim:*
3.	Statement of alleged victim (give a detailed summary below):*
4.	Name(s) of person(s) accused:*
	Relationship of the person(s) accused to the victim:* Paid Staff        Volunteer        Friend        Other:
	Date/time of the conversation with the accused:*
	Statement made by accused (give a detailed summary below):*
5.	Please indicate if report was made to one of the following:
	Pastor Administrative Council Chairperson Pastor/Staff Parish Relations Committee Chairperson
	Date/time of report:
	Summary of report:
6.	Call to alleged victim's parent/guardian:
	Spoke with:
	Date/time:
	Summary of call:
7.	Call to local Family and Children Service Agency:
	Name/job title of person spoken to:
	Date/time:
	Case no. assigned:
	Summary of call:
8.	Call to Law Enforcement Agency:
	Name/job title of person spoken to:
	Date/time:
	Summary of call:
9.	Other Contact:
	Date/time:
	Summary of call:
	(*Required information)