To be filled out and submitted to the People & Program Development Director immediately. Please confirm that this has been received by HR.

See the bottom of this form for definitions and the CYFC policy.

*Note: Considering the importance of this form, please insure it has been received by the correct department after any online submission. 

Name of Child/Youth Involved in Incident *
Name of Child/Youth Involved in Incident
Date of awareness/conversation with client
Date of awareness/conversation with client
Name of Guardian/Foster Home
Name of Guardian/Foster Home
Address of Child/Youth's home
Address of Child/Youth's home
(If Child/Youth is not living in a home, please list name of shelter or indicate if they are homeless with no landing address)
As per definition which is listed at the bottom of this page for your review
Include date(s) and time(s)
Name of Social Worker to receive report
Name of Social Worker to receive report
Name of Police Officer
Name of Police Officer
Your Name
Your Name

CALGARY YFC POLICY REGARDING SUSPECTED ABUSE

5.4.5. Suspected Abuse: It is legally required to report to Intervention Services Intake Line at (403) 297-2995 or police (911 or non-emergency 403.266.1234) any youth under 18 years of age suspected to have been abused or to be at risk of receiving or inflicting sexual, physical or emotional abuse or violence. Below is the procedure is to be followed.     

5.4.6. Abuse Defined: The Alberta Child and Family Services Act defines abuse as: "infliction of physical harm by the person having charge of the child, or physical harm caused by that person's failure to care for and provide the necessities of life or supervise and protect that child adequately; sexual molestation or sexual exploitation by the person having charge of the child or by another person where the person having charge of the child knows or should know of the possibility of sexual molestation or sexual exploitation and fails to protect the child; infliction of physical harm or suffering such that the child requires medical treatment to cure, prevent or alleviate the physical harm or suffering; infliction of emotional harm, demonstrated by severe:  anxiety, and/or depression, and/or withdrawal, and/or self-destructive or aggressive behaviour; failure to provide or consent to treatment to remedy or alleviate a mental, emotional or developmental condition that, if not remedied, could seriously impair the child's development."  

 5.4.7.  Process: Step 1: The staff member or volunteer who suspects abuse must not investigate or ask further questions of the youth or child or their family. Step 2:  The staff member or volunteer who suspects abuse must immediately notify their Supervisor and the Ministry Director or Executive Director, even if they are uncertain. Step 3:  The staff member or volunteer will immediately write their observations, a verbatim report of any disclosure, and a Suspected Abuse Report using the form available from The People and Program Development Director, all to be submitted as soon as possible, to the Ministry Director or Executive Director. Step 4:  The determination of whether the staff member or volunteer is to report to Alberta Child and Family Services will be made by the Ministry Director or Executive Director.