Step 1. Gather and Document Pertinent Information
Clarify and document all contact information, the abuse concern, the child/adolescent's
name and age, and the date and time of the call or intake.
Ask the caller or presenting caregiver to answer the questions below to the best of
his or her ability. The adult should not question the child/adolescent further if some
of the information is unavailable. When asking questions, be careful not to use the
words "alleged" or other legal terminology to refer to the incident.
Who are you and what is your relationship to the child/adolescent?
What is your reason for concern regarding abuse?
Is this a referral from a child abuse investigative agency?
Have you witnessed the abuse?
Did the child/adolescent disclose abuse? If so, to whom was the disclosure made?
What are the exact words the child/adolescent used?
Is the child/adolescent safe from the suspected perpetrator now?
Are you safe? Do you think your present situation is dangerous?
Is there a medical concern such as bruising, bleeding, vaginal discharge, or
Did the incident occur within 96 hours?
Step 2. Determine the Safety and Welfare of the Child/Adolescent
Is this child/adolescent safe? If not, and safety cannot be assured prior to
transport to an evaluation, make an immediate report to authorities (police and/or
Child Protective Services). Does this child/adolescent require hospitalization in
order to protect him or her from further harm?
Step 3. Determine Who Should Examine the Child/Adolescent and When
If the child/adolescent has any of the following and has presented to a primary care office setting, a local emergency response team should be notified with appropriate referral to an Emergency Department.
Symptoms of head trauma: vomiting, headache, syncope, lethargy, visual disturbance
Symptoms of abdominal injury: vomiting, abdominal pain, bruising to the abdomen/flank/back, hematuria
Symptoms or history of recent traumatic sexual contact: bleeding from the vagina or rectum, genital pain, or other signs of injury
If the incident is within 96 hours and the child/adolescent is medically stable, refer to the appropriate local resource, an Emergency Department or specialized center, for evidence collection.
Most exams are not an emergency. If the child/adolescent is safe, the examination can usually be deferred until the next working day. If there is a local child abuse expert, refer the child/adolescent to that medical provider. If this is not an option, proper photo-documentation and clear medical record documentation of the examination is essential so that a child abuse medical provider can interpret the findings. If your facility does not offer the appropriate services for medical care, determine which facility offers the best services for this child/adolescent and family. For more information, see TRIAGE: Appropriate Level of Care.
If you have a reasonable suspicion that sexual abuse was perpetrated by a legally responsible
adult, or that the abuse occurred because of the neglect of the legally responsible
adult, you have a responsibility to report this suspicion. In most cases, the
concern should be reported now if the family is being referred to another facility.
If the family will be seen at your facility, in most cases the report can be made after a
complete evaluation. For more information on reporting, see REPORTING: When to Report.