Design Two Interventions

Read the following case studies:

  1. Case Study: Joshua
  2. Case Study: Desert Viejo Elementary School

Create one 10-12-slide PowerPoint presentation (in addition to a title slide and references slide) outlining an intervention for each case study. One of the interventions must include Critical Incident Stress Debriefing (CISD). It is up to you to decide which type of intervention is best suited for each scenario. Include the following in your interventions:

  1. Step-by-step description of each intervention plan
  2. Rationale for choosing each intervention
  3. Community resources that are available in your local community that you would include as part of an intervention for each scenario

Include a minimum of three scholarly references in addition to the textbook.

Case Study: Joshua

 

Name: Joshua

 

Demographics

 

Joshua is a 17-year-old Caucasian male. Joshua is a junior in high school and his parents report he is an “average” student, earning Bs & Cs a majority of the time. Joshua is the youngest of four children, his two eldest siblings no longer live in the family home. Joshua’s 19-year-old sister lives in the family home while she attends the local college. Joshua is a medium build

 

Treatment History

 

Joshua was hospitalized last year for a substance abuse disorder. Joshua has been using drugs and alcohol since his 12th year.

 

Current Treatment

 

Joshua reports he has no current therapist, “They just don’t listen to me and even when they do they don’t understand my issues.”

 

Current Disposition

 

Joshua has called the hotline reporting “I just don’t see any reason to go on.” Joshua reports that his girlfriend recently broke with him and he has been feeling hopeless about his future. Joshua reports that he plans to “Play in traffic” soon.

 

 

© 2014. Grand Canyon University. All Rights Reserved.

Function Based Intervention

Part 1:

Create a scatter plot for an identified behavior within your workplace, report your results, and explain any patterns that may exist. Your post should be a minimum of 500 words long and supported with appropriate scholarly references. As you create your scatter plot, pay attention to the following three objectives of the activity.

 

  1. You must use dimensions of ABA to evaluate whether interventions are behavior analytic in nature.
  2. You must select function-based interventions after addressing response effort, practitioner skills, contextual fit, practicality, treatment acceptability, and administrative support.
  3. You must describe assessment results and interventions in language appropriate for practitioners (i.e., without technical jargon, without mentalistic explanations).

Part 2:

How will the information in the attached PowerPoint presentation prove applicable to your work as a behavior analyst? How did this general discussion help broaden your understanding of the unit’s objectives? Be sure to support your reflection and observations with scholarly references, where applicable.

References to be utilized:

Cooper, Heron & Heward Applied Behavior Analysis 2007/2012

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Chapter 23:
Antecedent Interventions

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Conceptual Understanding of Antecedent Interventions

  • Literature has classified all antecedent-based behavior change strategies under single terms
  • e.g. antecedent procedures, antecedent control, antecedent manipulations, antecedent interventions
  • Using the same terms may cause confusion or fail to recognize the different functions

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Conceptual Understanding of Antecedent Interventions

  • SD’s – evoke behavior due to past correlation with increased availability of reinforcement
  • MO’s – increase current frequency of behavior when an effective reinforcer is not available
  • Each has different implications for how behavior change strategies should be implemented and manipulated

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Classifying Functions of Antecedent Stimuli

  • Categories for functions of antecedent stimuli
  • Contingency dependent
  • Contingency independent

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Classifying Functions of Antecedent Stimuli

  • Contingency dependent
  • Antecedent event is dependent on the consequences of behavior for developing evocative & abative effects
  • All stimulus control functions
  • Referred to as antecedent control

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Classifying Functions of Antecedent Stimuli

  • Contingency independent
  • Antecedent event is not dependent on the consequences of behavior for developing evocative & abative effects
  • Antecedent itself affects behavior-consequence relations
  • MO’s are contingency independent
  • Referred to as antecedent intervention

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Antecedent Intervention

  • Antecedent interventions serve to have abolishing operations
  • Used in isolation or in combination (i.e. treatment packages
  • Decrease the effectiveness of reinforcers that maintain problem behavior
  • Effects of MO’s are temporary (Smith & Iwata, 1997)
  • Will not produce permanent improvements in behavior
  • Can be used simultaneously to reduce problem behavior
  • Most often antecedent interventions serve as a component of treatment package
  • Produce more maintaining effects

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Antecedent Intervention

  • Interventions with established experimental results
  • Noncontingent reinforcement (NCR)
  • High-probability request sequence
  • Functional communication training (FCT)

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • NCR is an antecedent intervention
  • Stimuli with known reinforcing properties are delivered on a fixed-time (FT) or variable-time (VT) schedule independent of the learner’s behavior (Vollmer et al., 1993)

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • May effectively decrease problem behavior because reinforcers that maintain the problem behavior are available freely & frequently
  • Functions as an abolishing operation (AO)
  • Referred to as presenting stimuli with known reinforcing properties

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • Uses three distinct procedures that identify & deliver stimuli with known reinforcing properties
  • Positive reinforcement
  • Negative reinforcement
  • Automatic reinforcement

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • NCR with positive reinforcement
  • Kahng, Iwata, Thompson, and Hanley (2000)
  • Study demonstrated the use of positive reinforcement (i.e. attention & food) for three individuals with developmental disabilities as an antecedent intervention to decrease problem behaviors found during analysis to be maintained by the positive reinforcement

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • NCR with negative reinforcement
  • Kodak, Miltenberger, and Romaniuk (2003)
  • Study demonstrated the use of negative reinforcment (i.e. break from instructional requests) for two individuals with autism as an antecedent intervention t decrease problem behaviors found during analysis to be maintained by negative reinforcement
  • Increased participants’ compliance & decreased problem behaviors

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • NCR with automatic reinforcement
  • Lindberg, Iwata, Roscoe, Worsdell, and Hanley (2003)
  • Study demonstrated the use of automatic reinforcement (i.e. physical manipulation of highly preferred leisure items) for two individuals with profound mental retardation to decrease SIB found during analysis to be maintained by automatic reinforcement
  • Demonstrated that NCR object manipulation could compete with automatic reinforcement to reduce SIB

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • Using NCR effectively
  • Three key elements to enhance effectiveness
  • Amount & quality of stimuli with known reinforcing effectiveness of NCR
  • Inclusion of extinction with NCR interventions
  • Vary the available stimuli with NCR intervention to reduce problems of changing preferences
  • Proper utilization of information obtained through FBA
  • Correct identification of maintaining contingencies of reinforcement

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • Ringdahl, Vollmer, Borrero, and Connell (2001)
  • Study demonstrates the importance of the schedule under which reinforcement is delivered in NCR
  • Similarities between baseline and initial NCR may be ineffective
  • Denser reinforcement (than during baseline) during initial NCR ensures discrepancy & better chances for intervention to be successful

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • Ringdahl et al. (2001) suggest three procedures for emphasizing reinforcement during NCR intervention
  • Increase the delivery of stimuli with known reinforcing properties
  • Use an obviously different schedule of reinforcement at treatment onset
  • Combine DRO with the NCR treatment package

 

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcment

  • Time schedules for NCR
  • Typically most applications use a FT schedule
  • Also can be done using a VT schedule
  • Establishing the initial schedule is crucial & can impact the overall effectiveness of the intervention
  • Recommendation is to start with a dense FT or VT schedule
  • Can be done arbitrarily
  • More effective to base it on the number of occurrences of problem behavior

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • To determine the initial NCR schedule
  • Divide the total duration of all baseline sessions by the total number of occurrences of the problem behavior (during baseline)
  • Set the initial interval at or slightly below the quotient

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • Thinning the time-based schedules
  • Completed by adding small time increments to the NCR interval
  • Best done after the initial NCR interval has produced reduction in problem behavior
  • Can be accomplished using three procedures
  • Constant time increases
  • Proportional time increases
  • Session-to-session time increase or decrease

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • Constant time increases
  • Increase the FT or VT schedule intervals by using a constant duration of time
  • Decrease the amount of time the individual has access to the SCR stimuli by a constant duration of time

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • Proportional time increase
  • Increase the FT or VT schedule interval proportionately
  • Each time the schedule is increased by the same amount of time

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • Session-to-session time increase or decrease
  • Use the individual’s performance to change the schedule interval on a session-to-session basis

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

Noncontingent Reinforcement

  • Additional considerations for NCR
  • Establish a terminal criteria
  • Weigh the possible advantages against possible disadvantages before deciding to utilize NCR with any indivdual

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

High-Probability
Request Sequence

  • Referred to as high-p request sequence
  • Delivery of a high-p request sequence involves
  • Presentation of a series of easy-to-follow requests for which the individual has a history of compliance (i.e. high-p requests)
  • When individual complies with several high-p requests, provide individual with target request (i.e. low-p)

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

High-Probability
Request Sequence

  • Behavioral effects of high-p request sequence suggests the abative effects of an AO by
  • Reducing the value of reinforcement for non-compliance to low-p requests
  • Reducing the aggression & self-injury typically associated with low-p requests
  • Provides non-aversive procedure for improving compliance by diminishing escape-maintained problem behaviors
  • May decrease excessive slowness in responding to requests & increase time used for completing tasks

Cooper, Heron, and Heward

Applied Behavior Analysis, Second Edition

Copyright © 2007 by Pearson Education, Inc.

All rights reserved

High-Probability
Request Sequence

  • Apply the high-p request sequence by
  • Selecting 2-5 short tasks with which the individual has a history of compliance
  • Present the high-p request s

Psychological Report-The Characther Is Beethoven

For your Final Paper, you will demonstrate your knowledge of psychopathology and apply your skills to a realistic scenario. Throughout this course, you have developed unique knowledge and skill sets that will allow you to critically analyze depictions of psychopathology in popular media and historical case examples from an informed point of view.

Your Final Paper will be a psychological report that may be based on a character from a movie or a historical case study. Review the provided lists of moviesPreview the document and historical case studiesPreview the document that are approved for use in this assignment.  You must choose from these lists. You may not use examples from your personal life in the psychological report since doing so would be unethical (see Standards 2.04 and 9.01a in the Ethical Principles of Psychologists and Code of Conduct).

As you create this report, you will be taking on the role of a clinician who is conducting an assessment and providing treatment recommendations for a patient (a character from your selected film or historical case study). Please note that a psychological report does not follow the same structure for reports you may have used in other courses. Your report must follow the format below and it must include each of the sections and their headings listed in this order:

  1. Identifying Information
    Within this section, you will describe basic information on your patient, including the person’s name, sex, gender, sexual orientation, age, race, occupation, and location of residence (country, state, and region).
  2. Chief Complaint/Presenting Problem
    Within this section, you will include the patient’s primary complaint verbatim to identify the main source of his or her distress and/or concerns. If there is no verbatim complaint, include observable information to create an overall picture of the presenting problem.

    Typically, this section within a psychological report seeks to address the following question (further elaboration within this section is encouraged where possible):

    • What are the patient’s complaints? (e.g., the patient might complain about “feeling on edge” or experiencing stress)
  3. Symptoms
    Within this section, you will interpret specific behavioral issues and intrapsychic conflicts as they relate to abnormal behavior, behavior patterns, maladaptive thought processes, and potential unconscious conflicts. Interpret and comment on the patient’s chief complaint and/or presenting problem in the context and language of the symptoms found in the DSM-5. (e.g., the patient who complains about “feeling on edge” might actually be experiencing symptoms related to post-traumatic stress disorder or generalized anxiety disorder)
  4. Personal History
    Within this section, you will analyze your patient’s personal background and history of abnormal behavior(s) that inform your diagnostic impression. You will also gather information about the patient’s cultural background and cultural norms.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

    • Where did the patient grow up?
    • What cultures did the patient experience throughout life?
    • What was the patient’s school life like?
    • What were his or her grades? What is his or her highest level of education?
    • What is the patient’s interpersonal relationship history?
    • What was/is the patient’s romantic relationship history?
    • What was/is the patient’s friendship history?
  5. Family History
    Within this section, you will analyze the patient’s familial relationship(s) and identify any abnormalities that might affect future treatment. You will also integrate information about the patient’s family and cultural background to identify any maladaptive behaviors and relational patterns.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

    • How old were the patient’s parents when the patient was born?
    • Who were the patient’s primary caregivers?
    • What was/is family life like? (Include any information relevant to your diagnostic impression.)
    • Did the family move often?
    • What was/is the patient’s relationship with their siblings (if applicable)?
    • What culture did/does the family come from?
    • What belief systems are attached to that culture?
  6. Therapy History
    Within this section, you will describe the patient’s therapy history to inform your diagnostic impression. Analyze the patient’s therapy history to identify the effectiveness of previous treatment(s). Analyze previous treatment interventions based on information and knowledge of the patient’s cultural background.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

    • Who was the previous therapist (if applicable)?
    • How long did the previous therapy/therapies last?
    • What was the patient’s diagnosis?
    • What interventions did the therapist(s) use?
    • Were those interventions appropriate for the patient’s culture?
    • Was treatment successful?
  7. Medical Conditions
    Within this section, you will analyze the patient’s medical history and comment on any possible medical conditions that could influence your diagnostic impression. Interpret specific behavioral issues as they relate to salient medical conditions. If the person has any medical conditions, indicate that in this section. Integrate information and knowledge about the patient’s cultural background as it affects treatment options for medical conditions.
  8. Substance Use
    Within this section, you will analyze and comment on the patient’s substance use to identify any potential issues that could influence your diagnostic impression. Interpret specific behavioral issues as they relate to substance use. If the person misuses specific substances, indicate that in this section. Integrate information and knowledge about the patient’s cultural background to inform your interpretation of substance misuse in this patient’s case.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

    • Which substances does the patient use? (Include any over-the-counter, herbal, and/or prescription medications.)
    • For how long has the patient used the substance?
    • What is the patient’s quantity and frequency of use?
  9. Collateral
    Within this section, you will interpret specific collateral information as it relates to your patient’s abnormal behavior and behavior patterns. You will also integrate information and knowledge regarding the patient’s culture in your evaluation of the maladaptive behavior as reported by the collateral sources.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

    • What do other people have to say about the patient’s behavior?
    • Are there any commonalities between the collateral sources’ reports?
    • Do the collateral sources have any psychological issues that might exacerbate the patient’s problems?
    • Are there any police reports?
    • Are there any personality testing or intelligence testing reports available?
  10. Results of Evaluation
    Within this section, you will analyze the patient’s behavior and mental processes. There are two parts to this section. To begin your analysis, you will write a brief evaluation of each theory of personality development that you learned about in this course and determine whether or not each theoretical orientation can be used to conceptualize the patient’s current situation and treatment goals. Next, use one major theoretical orientation to write an in-depth analysis for your results of evaluation section. Within the context of this theoretical perspective, you will analyze all of the information from the previous sections. Analyze specific behaviors, cognitions, and intrapsychic processes as they relate to your diagnostic impression. Integrate knowledge of the patient’s cultural background and norms within that culture as you prepare your supporting evidence.

    Typically, this section within a psychological report seeks to answer the following question (further elaboration within this section is encouraged where possible):

    • Based on the information you gathered in the previous sections, what led to the patient’s current state?
  11. Diagnostic Impression With Differential Justification
    Within this section, you will provide your diagnosis for the patient. To demonstrate your understanding of diagnostic procedure and justification, specifically address each symptom that the patient displayed and relate each symptom to a diagnostic criterion in the DSM-5. Analyze the patient’s behaviors and mental processes within your differential justification. Clearly demonstrate that the patient meets criteria to be given a diagnosis. If the patient does not meet criteria for any diagnosis based on your assessment, explain why. Also, explore any alternative diagnoses and explain why these were not chosen.
  12. Recommendations
    Within this section, you will you provide treatment recommendations for the person to help them improve his or her quality of life. These recommendations must be based on the theoretical orientation you used in your Results of Evaluation. Explain why you chose your treatment intervention(s) and include peer-reviewed articles that support your choice(s). If treatment is not necessary, explain why. Pay close attention to the person’s culture since some treatment options may be insensitive to his or her culture or way of living.

Writing the Final Paper

The Final Paper:

  1. Must follow the report outline provided above with the requisite headings and be formatted according to APA style as outlined in the Ashford Writing Center.
  2. Must include a title page with the following:
    1. Title of paper
    2. Student’s name
    3. Course name and number
    4. Instructor’s name
    5. Date submitted
  3. Must address the assessment with critical thought.
  4. Must use at least five peer-reviewed sources that were published within the last ten years, in addition to the text, a minimum of four must be from the Ashford University Library.
  5. Must document all sources in APA style as outlined in the Ashford Writing Center.

Describe local laws regulating the practice of psychology

Child Abuse Case Analysis

In this assignment you are required to perform a child abuse assessment utilizing the child abuse reporting form, located in the Resource section of your syllabus.

PSY 87504_ChildAbuseReportForm.pdf (PLEASE SEE ATTACHED DOCUMENT)
It is suggested that you print the form, fill it out, scan and upload as a pdf file.

Review this week’s video and the reading assignments on child abuse assessment. Using the above Assessment tool, please evaluate the following vignette for suspicion of child abuse.
Fill out the form, describing what you see in the vignette that supports your assessment responses.

After you fill out the form, write a paper discussing your assessment, possible interventions and prevention strategies that you might use when encountering  similar situations in your professional work.  Justify your responses by using and referencing the course text and the video that you watched this week.  All work must be written in graduate level English in APA format.

Your paper should be 1-2 pages plus a title and reference page.

Dave, a 16-year old boy, is seen in an intake counseling session accompanied by his mother. His mother is worried because Dave is so angry.  Dave tells you that he hates his parents. He tells you that he is sick of his father’s alcoholic rages and his mother making excuses for them. Mom tells you that Dave will argue and pick a fight with his father when Dad is drinking.  Often times, this ends with fights between Dave and his Dad.  On more than one occasion Dave has suffered from a black eye. Dave tells you that he only picks these fights to protect his 12-year old brother by “getting the heat off of him”. Mom tells you that it’s always impossible for her to tell who started the physical fight and asks what she should do.
Assignment Outcomes

Recognize the major issues related to sound and professional practice in psychology

Assess and evaluate legal and ethical mandates in clinical context

Describe local laws regulating the practice of psychology

NAME OF MANDATED REPORTER TITLE MANDATED REPORTER CATEGORY

REPORTER’S BUSINESS/AGENCY NAME AND ADDRESS Street City Zip DID MANDATED REPORTER WITNESS THE INCIDENT?

❒ YES ❒ NO

REPORTER’S TELEPHONE (DAYTIME) SIGNATURE TODAY’S DATE

( )

❒ LAW ENFORCEMENT ❒ COUNTY PROBATION AGENCY

❒ COUNTY WELFARE / CPS (Child Protective Services)

ADDRESS Street City Zip DATE/TIME OF PHONE CALL

OFFICIAL CONTACTED – TITLE TELEPHONE

( )

NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY

ADDRESS Street City Zip TELEPHONE

( )

PRESENT LOCATION OF VICTIM SCHOOL CLASS GRADE

PHYSICALLY DISABLED? DEVELOPMENTALLY DISABLED? OTHER DISABILITY (SPECIFY) PRIMARY LANGUAGE

❘❒ YES ❒ NO ❒ YES ❒ NO SPOKEN IN HOME

IN FOSTER CARE? IF VICTIM WAS IN OUT-OF-HOME CARE AT TIME OF INCIDENT, CHECK TYPE OF CARE: TYPE OF ABUSE (CHECK ONE OR MORE)

❒ YES ❒ DAY CARE ❒ CHILD CARE CENTER ❒ FOSTER FAMILY HOME ❒ FAMILY FRIEND ❒ PHYSICAL ❒ MENTAL ❒ SEXUAL ❒ NEGLECT

❒ NO ❒ GROUP HOME OR INSTITUTION ❒ RELATIVE’S HOME ❒ OTHER (SPECIFY)

RELATIONSHIP TO SUSPECT PHOTOS TAKEN? DID THE INCIDENT RESULT IN THIS

❒ YES ❒ NO VICTIM’S DEATH? ❒ YES ❒ NO ❒ UNK

NAME BIRTHDATE SEX ETHNICITY NAME BIRTHDATE SEX ETHNICITY

1. 3.

2. 4.

NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY

ADDRESS Street City Zip HOME PHONE BUSINESS PHONE

( ) ( )

NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY

ADDRESS Street City Zip HOME PHONE BUSINESS PHONE

( ) ( )

SUSPECT’S NAME (LAST, FIRST, MIDDLE) BIRTHDATE OR APPROX. AGE SEX ETHNICITY

ADDRESS Street City Zip TELEPHONE

( )

OTHER RELEVANT INFORMATION

IF NECESSARY, ATTACH EXTRA SHEET(S) OR OTHER FORM(S) AND CHECK THIS BOX IF MULTIPLE VICTIMS, INDICATE NUMBER:

DATE / TIME OF INCIDENT PLACE OF INCIDENT

NARRATIVE DESCRIPTION (What victim(s) said/what the mandated reporter observed/what person accompanying the victim(s) said/similar or past incidents involving the victim(s) or suspect)

A .

R E

P O

R T

I N

G

P A

R T

Y

❒

D . I N

V O

L V

E D

P

A R

T I E

S

V I C

T I M

‘S

S I B

L I N

G S

SUSPECTED CHILD ABUSE REPORT

DEFINITIONS AND INSTRUCTIONS ON REVERSE

DO NOT submit a copy of this form to the Department of Justice (DOJ). The investigating agency is required under Penal Code Section 11169 to submit to DOJ a

Child Abuse Investigation Report Form SS 8583 if (1) an active investigation was conducted and (2) the incident was determined not to be unfounded.

WHITE COPY-Police or Sheriff’s Department; BLUE COPY-County Welfare or Probation Department; GREEN COPY- District Attorney’s Office; YELLOW COPY-Reporting Party

SS 8572 (Rev. 12/02)

B . R

E P

O R

T

N O

T I F

I C

A T

I O

N

E . I N

C I D

E N

T I N

F O

R M

A T

I O

N

S U

S P

E C

T

V I C

T I M

‘S

P A

R E

N T

S / G

U A

R D

I A

N S

CASE NAME:

CASE NUMBER:

To Be Completed by Mandated Child Abuse Reporters

Pursuant to Penal Code Section 11166

PLEASE PRINT OR TYPE

C . V

I C

T I M

O n

e r e p

o r t p

e r v i c t i m

 

  1. case name:
  2. case number:
  3. Button2:
  4. A name of mandated reporter:
  5. A title:
  6. A mandated reporter category:
  7. Text4:
  8. Yes:
  9. no:
  10. A area code:
  11. A phone number:
  12. A today’s date:
  13. Text10:
  14. B county prob:
  15. B county welfare:
  16. B agency:
  17. B address:
  18. date/time of phone call:
  19. B official contacted – title:
  20. B area code:
  21. Text18:
  22. C last first middle:
  23. C birthdate or age:
  24. C sex:
  25. c ethnicity:
  26. C address:
  27. C area code:
  28. C phone number:
  29. C location of victim:
  30. C school:
  31. C class:
  32. C grade:
  33. C1 yes:
  34. C1 no:
  35. C2 yes:
  36. C2 no:
  37. C other disability:
  38. C language spoken:
  39. C3 yes:
  40. C3 no:
  41. C day:
  42. c ccc:
  43. c foster:
  44. C fam friend:
  45. C group:
  46. C relative:
  47. C phy:
  48. C mental:
  49. C sexual:
  50. C neg:
  51. C other:
  52. Text49:
  53. C relationship:
  54. C photos yes:
  55. C photos no:
  56. C death yes:
  57. C death no:
  58. C unknown:
  59. Text56:
  60. D sib 2:
  61. D sib 3:
  62. D sib 4:
  63. D name:
  64. D birthdate:
  65. D sex:
  66. D ethnicity:
  67. D address:
  68. D area:
  69. D phone:
  70. D area b:
  71. D phone b:
  72. Name2:
  73. D birthdate 2:
  74. D sex 2:
  75. D ethnicity 2:
  76. D address 2:
  77. D area 2:
  78. D phone 2:
  79. D area b2:
  80. D phone b2:
  81. DS name:
  82. DS birthdate:
  83. DS sex:
  84. Text81:
  85. DS address:
  86. DS area:
  87. DS phone:
  88. Text85:
  89. E check box:
  90. E number multiple victims:
  91. E date and time:
  92. E place of incident:
  93. E narrative:
  94. Button1: