Suspected Abuse and Neglect

To be completed, to the best of your ability, by a staff member at CedarCreek Church with the cooperation of the person reporting the incident.

Have you talked with your Supervisor and sent an email to your Supervisor, Campus Pastor, Ministry Director, HR Director and the respective Executive Directors to notify all parties of the situation? *

Yes

Please confirm that you have filled out a Care Note in Rock and communicated with the appropriate staff members per CreekHelp Standard. *

Yes

Name of CedarCreek Church staff member reporting:

Your First Name *

You Last Name *

Your Email *

Supervisor Email *

Campus *

Date & Time

What information do you have? *

Person Reporting to CedarCreek

Victim

Parent / Guardian / Caretaker

Alleged Perpetrator

Person Reporting to CedarCreek:

First Name: *

Last Name: *

How are they connected to CedarCreek: *

Additional Details: *

Victim Information:

First Name *

Last Name *

Birthdate *

Gender *

Address *

Address

City

State/Province

Zip/Postal

Country

Location of victim during the week: *

ex: School or daycare

Date of conversation with/on behalf of victim: *

Place of conversation with/on behalf of victim: *

Reason of suspected abuse/neglect: *

Parent / Guardian / Caretaker Information

First Name: *

Last Name: *

Address *

Address

City

State/Province

Zip/Postal

Country

Immediate risks for caseworker visiting the home: *

ex: dogs, weapons, mental illness, criminal history

Alleged Perpetrator Information:

First Name: *

Last Name: *

Relationship to victim: *

Address

City

State/Province

Zip/Postal

Country

Additional Details: *

Call to Local Children and Family Service Agency

Name of Agency: *

Name of Contact: *

Date *

Time *

Summary of Conversation *

Call to Local Law Enforcement

Name of Agency:

Name of Contact:

Date

Time

Summary of Conversation

Signature of CedarCreek Staff Member *

Clear

Printed Name of CedarCreek Staff Member *