Central Vineyard Child Safety Report

Is the child in immediate danger? (If so, please contact child services or the police immediately.

Yes (call police or child services immediately) No

Contact info

Name of Report Filer

This address will receive a confirmation email

Phone

Incident report

Date of incident

Time of incident

Location of Incident (Specific Rooms and other details are helpful)

Who witnessed the incident? (Please name all witnesses you are aware of.)

Please describe the incident.

Describe your response to the incident.

If you are entering data from a paper form that you did not fill out yourself, please note your name:

Description

Thank you for filing a child safety report. Child protection is of the utmost importance to us. The more complete your report, the more it will help us address areas of concern promptly and effectively. Please fill out this form and click submit.

Central Vineyard Child Safety Report

Description

Please Fix the Following