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Suspected Child Abuse Report Form

Suspected Child Abuse Report Form

If you believe you may have witnessed child abuse on campus, you may either complete this form or call us 845-574-4217.

Information About the Incident

Date and Time of Occurrence
/ /   :
Type of Abuse
check all that apply
Be as specific and detailed as possible to the best of your recollection.

Information About the Victim(s)

approximate age if known

Information About the Abuser

Information About Additional Witnesses

Were there any witnesses to the situation or treatment you have described other than yourself?

Who Have You Shared This Experience With So Far?

Have you spoken to anyone about your concerns?

Confidentiality Statement

Public Safety will make every effort to maintain confidentiality except in situations where law, College policy, or the investigatory process requires the release of information. Each complaint will be investigated to the best of the College’s ability, based upon the information provided.

Retaliation against an individual who reports suspected child abuse/inappropriate contact is strictly prohibited.

Information About You (the person filing this report)

Preferred Method of Contact

College Affiliation

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