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STATE OF CALIFORNIA BCIA 8583 Orig. 06/2005 Rev 03/2013 DEPARTMENT OF JUSTICE Print Form Reset Form Save Form CHILD ABUSE OR SEVERE NEGLECT INDEXING FORM To be completed by Submitting Child Protective Agency pursuant to Penal Code PC section 11169 INITIAL REPORT DOJ USE ONLY RCN AGENCY C. AMENDED REPORT INFORMATION B. INCIDENT A. SUBMITTING AGENCY SUBMITTING AGENCY Enter complete name and check type AGENCY ADDRESS WELFARE Street Zip Code AGENCY TELEPHONE DATE OF REPORT THE FINDING THAT ALLEGATIONS OF CHILD ABUSE OR SEVERE NEGLECT IS SUBSTANTIATED PC sections 11165. 12 b and 11169 a DATE OF INCIDENT TYPE OF ABUSE Check one or more PHYSICAL INJURY MENTAL/EMOTIONAL SUFFERING SEXUAL ABUSE ASSAULT EXPLOITATION SEVERE NEGLECT WILLFUL HARMING/ENDANGERMENT UNLAWFUL CORPORAL PUNISHMENT OR INJURY ORIGINAL AGENCY REPORT NUMBER/CASE NAME DATE OF NOW UNFOUNDED OR INCONCLUSIVE ADDED ADDITIONAL INFORMATION CORRECTED REPORT INFORMATION UNDERLYING INVESTIGATIVE FILE NO LONGER AVAILABLE COMMENTS Last First YES VICTIM S State TITLE Middle AKA DID VICTIM S INJURIES RESULT IN DEATH NAME UNKNOWN ADDRESS RACE FEMALE DOB City PARENT/STEPPARENT NO RELATIONSHIP TO VICTIM SUSPECT IS AGE 17 OR YOUNGER MALE IS VICTIM DEVELOPMENTALLY DISABLED 4512 a W I Approx. AGE D. INVOLVED PARTIES SUSPECT AGENCY REPORT NUMBER/CASE NAME NAME OF SUBMITTING PARTY OTHER PROBATION SIBLING OTHER RELATIVE HGT WGT EYE C - Chinese J - Japanese A - Other Asian Z - Asian Indian D - Cambodian G - Guamanian SOCIAL SECURITY NUMBER DRIVER S LICENSE NUMBER FRIEND/ACQUAINTANCE RACE CODES W - White B - Black H - Hispanic I - American Indian F - Filipino P - Pacific Islander S - Samoan HAIR U - Hawaiian K - Korean L - Laotian V - Vietnamese O - Other X - Unknown STRANGER. AMENDED REPORT INFORMATION B. INCIDENT A. SUBMITTING AGENCY SUBMITTING AGENCY Enter complete name and check type AGENCY ADDRESS WELFARE Street Zip Code AGENCY TELEPHONE DATE OF REPORT THE FINDING THAT ALLEGATIONS OF CHILD ABUSE OR SEVERE NEGLECT IS SUBSTANTIATED PC sections 11165. 12 b and 11169 a DATE OF INCIDENT TYPE OF ABUSE Check one or more PHYSICAL INJURY MENTAL/EMOTIONAL SUFFERING SEXUAL ABUSE ASSAULT EXPLOITATION SEVERE NEGLECT WILLFUL HARMING/ENDANGERMENT UNLAWFUL CORPORAL PUNISHMENT OR INJURY ORIGINAL AGENCY REPORT NUMBER/CASE NAME DATE OF NOW UNFOUNDED OR INCONCLUSIVE ADDED ADDITIONAL INFORMATION CORRECTED REPORT INFORMATION UNDERLYING INVESTIGATIVE FILE NO LONGER AVAILABLE COMMENTS Last First YES VICTIM S State TITLE Middle AKA DID VICTIM S INJURIES RESULT IN DEATH NAME UNKNOWN ADDRESS RACE FEMALE DOB City PARENT/STEPPARENT NO RELATIONSHIP TO VICTIM SUSPECT IS AGE 17 OR YOUNGER MALE IS VICTIM DEVELOPMENTALLY DISABLED 4512 a W I Approx. 12 b and 11169 a DATE OF INCIDENT TYPE OF ABUSE Check one or more PHYSICAL INJURY MENTAL/EMOTIONAL SUFFERING SEXUAL ABUSE ASSAULT EXPLOITATION SEVERE NEGLECT WILLFUL HARMING/ENDANGERMENT UNLAWFUL CORPORAL PUNISHMENT OR INJURY ORIGINAL AGENCY REPORT NUMBER/CASE NAME DATE OF NOW UNFOUNDED OR INCONCLUSIVE ADDED ADDITIONAL INFORMATION CORRECTED REPORT INFORMATION UNDERLYING INVESTIGATIVE FILE NO LONGER AVAILABLE COMMENTS Last First YES VICTIM S State TITLE Middle AKA DID VICTIM S INJURIES RESULT IN DEATH NAME UNKNOWN ADDRESS RACE FEMALE DOB City PARENT/STEPPARENT NO RELATIONSHIP TO VICTIM SUSPECT IS AGE 17 OR YOUNGER MALE IS VICTIM DEVELOPMENTALLY DISABLED 4512 a W I Approx. AGE D. INVOLVED PARTIES SUSPECT AGENCY REPORT NUMBER/CASE NAME NAME OF SUBMITTING PARTY OTHER PROBATION SIBLING OTHER RELATIVE HGT WGT EYE C - Chinese J - Japanese A - Other Asian Z - Asian Indian D - Cambodian G - Guamanian SOCIAL SECURITY NUMBER DRIVER S LICENSE NUMBER FRIEND/ACQUAINTANCE RACE CODES W - White B - Black H - Hispanic I - American Indian F - Filipino P - Pacific Islander S - Samoan HAIR U - Hawaiian K - Korean L - Laotian V - Vietnamese O - Other X - Unknown STRANGER..

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