Report of suspected incident of child abuse

I understand that before I complete this report, I should make myself familiar with the laws of the state or North Carolina regarding the reporting of any incidence of child abuse. For more information, go to the Safe Sanctuary page on HUMC website. *

Date of suspected incident: *

Name of person accused of abuse: *

Relationship of accused abuser to victim: *

Name of worker observing or receiving disclosure of child abuse: *

Name of victim: *

Place of initial conversation with victim: *

Victim's statement: *

Any additional information you'd like to add:

Have you reported this incident to the Senior Pastor or any other staff member? *

Have you reported this incident to the event or ministry leader? *

Have you spoken to the victim's parent or guardian about this incident? *

Have you spoken with Child Protective Services? *

Have you reported this incident to law enforcement? *