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Abuse Claim
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Date of occurrence:
MM
/
DD
/
YYYY
Type of Concern:
Harassment
Exploitation
Policy violation with a minor
Possible risk of abuse
Known or suspected abuse
Other:
Clear selection
Has this been reported to the Texas Department of Family and Protective Services?
Yes
No
Clear selection
if reported, what's the report number?
Your answer
Describe the situation: (what happened, where it happened, who was involved, who was present, who was notified?) If reported to TDFPS, what are their recommendations or instructions?
Your answer
Has this situation occurred previously?
Yes
No
Clear selection
If Yes, when?
Your answer
What action was taken? (how was the situation handled, who was involved, were police called?)
Your answer
What is the follow-up plan? (does anyone else need to be notified, will the situation need monitoring, would you like a Diocesan representative to call you, will you answer questions from investigator?)
Your answer
Submitted by
Your answer
Telephone number
Your answer
Location and address:
Your answer
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