Observed

Check this box if the referent observed the situation first-hand.

Told by Another Party

Check this box if the referent was told of the situation by another person.

Date

Enter the date the referent observed the incident or the date the referent was told of the situation.

Source of Knowledge Narrative

Enter the name and contact details of the person who told the referent of the situation.  

The Referent has addressed concern...

Check this box if this statement applies to the referent.

If Checked, with Whom

Enter the names of the people with whom the referent raised his or her concerns.

Last Date and Time the Reporter had Contact with ACVs

Enter the date and time of the referent's last contact with the alleged children named in this intake.

Name and Contact Information of Others...

Enter the names, phone numbers, addresses, or email addresses of any others who have knowledge of the situation described by the referent.