NAME OG MANDATED REPORT Ellen P. Lacter, Ph.D. t tTLE Psychologist REPOR H S BUSINESS/AGENCY NAME ANI ADDRESS S reet 3505 Camlrm del Rio South, Suite 212, San Diego, CA 92108 City Zip DID MANDATED REPORTER WITNEss THE INCIDENT? O YES NO TODAY S DAYE 2/13/2008 D LAW ENFORCEMENT 3 COUNTY PROBA33ON COUNTY WELFARE I CPS (Child Ptotedive ervices) ADDRESS Street P.O. Box 7988, San Francisco CA 94120 AG .NCY Ch d Protective Services City Zip OFRCIAL CONTACTED- TITLE TELEPHO.

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How to fill out the 11166 Form online

Filling out the 11166 Form is an important step in reporting suspected child abuse. This guide offers a comprehensive approach to completing the form online, ensuring that you understand each section and can provide accurate information.

Follow the steps to complete the 11166 Form online.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Begin by filling in the case name and case number. Ensure that you write accurate details regarding the incident you are reporting.
  3. Provide the reporter's information. This includes the name of the mandated reporter, their title, agency name, and full address. Make sure all details are correct and up-to-date.
  4. Indicate whether the mandated reporter witnessed the incident by selecting 'Yes' or 'No'. Include the date of today’s report in the designated field.
  5. Complete the agency information section by listing the name and address of the agency contacted. Include the official's name, title, and telephone number.
  6. Fill out the victim's information including their birthdate or approximate age, sex, and ethnicity. This helps in identifying the victim accurately.
  7. Enter details regarding the present location of the victim. Include information about any disabilities and whether the victim is in foster care.
  8. If applicable, check the type of care the victim was in at the time of the incident, which can include foster care or other care types.
  9. Provide details about any potential subjects involved in the incident. Include names and significant information related to these individuals.
  10. Document any additional relevant information in the space provided, including a narrative description of what the victim disclosed or what the mandated reporter observed.
  11. Once you have completed the form, review all entries for accuracy. Upon finalization, use the options available to save changes, download, print, or share the form as needed.

Complete your documentation process effectively by filling out the 11166 Form online today.

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Questions & Answers

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Which reports must be reported to CACI?

Investigated reports of child abuse are forwarded to the CACI. These reports contain information related to substantiated cases of physical abuse, sexual abuse, mental/emotional abuse, and/or severe neglect of a child.

Risk factors. Some of the risk factors associated with family are static, while others are dynamic. Static risk factors, such as criminal history, parental mental health problems or a history of childhood abuse, are unlikely to change over time.

Structural/economic factors: The stress of poverty, unemployment, restricted mobility, and poor housing can be instrumental in a parent's ability to adequately care for a child. The child needs to be protected from separation from his/her family solely because of stressed economic conditions.

Parental Factors: Young, unsupported mother often with low education. Parents have unrealistic expectations of the child and lack parenting knowledge. Parent is isolated and has few supports. Parent has a mental illness or is abusing drugs or alcohol.

Reasonable suspicion of emotional abuse that must be reported often results from verbal disclosures or direct observation and involves any person willfully causing or permitting any child to suffer unjustifiable physical pain or mental suffering, or endangering the child's person or health (Penal Code 11165.3).

Mandated Reporters must report suspected child abuse or neglect. They must report to DFCS or the police at once or as soon as possible. In case of life threatening emergency, call 911. Mandated Reporter must also submit a completed Form 8572-Suspected Child Abuse Report.

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