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File Name___________

PASTOR’S LOG OF INITIAL CONTACTS RESULTING FROM


SUSPECTED INCIDENT OF CHILD ABUSE
(Note: It is imperative that the person filling out this report be familiar with the state law
reporting requirements before taking any action or completing this report. Each individual
involved in the reporting process should file a complete report to be filed with this summary.
Each report should be signed and dated.)

Name of Person Maintaining this log:

Report to pastor:
Person who made the contact:

Date/time:

Call to local children and family service agency, juvenile judge or law enforcement agency:
Person who made the contact:

Date/time:

Spoke with:

Summary:

Contact with victim’s parent/guardian (if appropriate):


Person who made the contact:

Date/time:

Spoke with:

Summary:

Page 1 of 2
This is a sample form. It needs to be modified to meet the specific needs of your congregation. For information
about creating policies and procedures for the safety of children and youth, please see Safe Sanctuaries, Safe
Sanctuaries for Youth, or Santuarios Seguros published by Discipleship Resources.

© 2006 The General Board of Discipleship; Permission is given to reproduce this form for churches who have
purchased Safe Sanctuaries published by Discipleship Resources.
File Name___________

Contact with District Superintendent: Name:

Person who made the contact:

Date/time

Spoke with:

Summary:

Contact with Insurance Provider: Name:

Person who made the contact:

Date/time:

Summary:

Contact with Spokesperson for the Congregation: Name:

Person who made the contact:

Date/time:

Summary:

Other contacts:
Contact Name:

Person who made the contact:

Date/time:

Summary:

Page 2 of 2
This is a sample form. It needs to be modified to meet the specific needs of your congregation. For information
about creating policies and procedures for the safety of children and youth, please see Safe Sanctuaries, Safe
Sanctuaries for Youth, or Santuarios Seguros published by Discipleship Resources.

© 2006 The General Board of Discipleship; Permission is given to reproduce this form for churches who have
purchased Safe Sanctuaries published by Discipleship Resources.

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