Children Services Report Form

Has the PCSA received the written request from the superintendent of public instruction for the information reported in this form?:

Does the prosecuting attorney intend to prosecute the alleged perpetrator?:

Has the prosecuting attorney determined this information may not be released?:

If the prosecuting attorney intends to prosecute, is there written authorization from the prosecuting attorney to release certain information?:

Today
Has Local Law Enforcement been involved:

Has Medical Treatment Been Provided to the Alleged Perpetrator:


Has Medical Treatment Been Provided to the Alleged Child Victim:

Will you be providing additional documentation or correspondence?:

How will you provide the additional documentation?:


Last Modified: 5/8/2013 3:36:45 PM