Anonymous Child Abuse/Neglect Reporting Form for Staff

Basic information about the incident. Please provide the following information to the best of your knowledge. All fields marked with a red asterisk * are required.   HS/EHS Center:   * Incident Date:   * mm/dd/yyyy format Incident Time:   * HH:MM format Location of incident:  Please choose incident locationOutside the buildingOfficeClassroomBusPlaygroundHallwayBathroomCafeteriaBuilding LobbyField TripOther * Please specify the location of the incident if not listed:  Classroom Number:   If the incident occurred in a classroom. Classroom Ratio:  Ratio of children to teachers e.g. 1 to 6, 2 to 8 ... etc. (If the incident occurred in a classroom) Number of Children Involved:   * Age of Children Involved:   *

Type of Incident (Please check all that apply, specify if not listed)    Serious Child Injury  Inadequate Supervision  Unauthorized Release  Potential Abuse, Neglect, or Inappropriate Conduct  Physical Abuse Type (Please check one of the following, check other and specify if not listed.)    Biting  Punching    Hitting  Pushing    Kicking  Shaking    Pinching  Throwing    Pulling  Corporal or Physical Punishment    Other:   Please specify  Verbal or Emotional Abuse  Sexual Abuse  Inappropriate Sexual Behavior  Neglect  Inappropriate Conduct  Other:  Please specify

Incident Description (Please describe the incident in details below)

Title and Employment Type (Please list titles and employment types of all adults involved in the incident. DO NOT write name.)     Employment Type   1. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual 2. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual 3. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual 4. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual 5. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual 6. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual 7. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual 8. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual 9. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual 10. Title of Individual:   Permanent  Temporary  Substitute  Volunteer  Contractual

Is this incident reported to anyone else other than Shore Up?                    Yes No  If yes, which one(s)? Check other and specify if not listed.  Licensing Agency or Tribal Report Date:   Law Enforcement Report Date:   Child Protective Services Report Date:   Governing Body Report Date:   Policy Council Report Date:   Other:  Please specify Report Date:

Thank you for reporting this incident to SHOP UP!, inc. Please be sure that your identity will absolutely stay anonyms. We will investigate the issue you have reported, and we will make every possible effort to correct it.