Report of Suspected Child Abuse/Neglect Completed Form Examples and Samples

Patient Intake Note - St. Jude’s Pediatric Urgent Care. Date: March 14, 2026. Attending Nurse: Sarah Jenkins, RN. Patient: Leo Miller (Male, 7 years old). Patient resides at 442 Maple Lane, Springfield, Sangamon County, IL 62704. Accompanied by his maternal aunt, Clara Vance, who brought the child in after noticing persistent bruising. Mother (Mary Miller, 122 Oak Street, Springfield, IL 62704, Sangamon County) was not present. Upon examination, I observed multiple contusions in various stages of healing across the child’s back and upper arms. When asked, Leo reported that his stepfather, Mark Thompson, had been 'rough with him' during a time-out yesterday. This is not the first instance; school records from early February suggest previous concerns, though no formal report was filed then. Currently, Leo is stabilized and remains under our care at the urgent care clinic. I am filing this report as a mandatory reporter. My facility is located at 900 Medical Plaza, Springfield, IL 62704. I am currently coordinating with Social Services to determine the immediate placement for the minor. No further physical trauma observed beyond the mentioned contusions. The patient is calm but appears withdrawn. We have cleared him for discharge once a guardian is identified by authorities.