Sample Journal Entry

If you are concerned about the safety of a child, we encourage you to trust your gut feelings. Sometimes vague feelings of discomfort or the sense that “something just isn’t right” can be an indication that something less visible is occurring in the background. Please take time to explore the situation further.  Use this form to keep track of the behaviors that concern you.  You can use this information to then talk with others about what you've witnessed.

Date of observed behavior(s):

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Child’s name & age if known:

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(Name)                                                               (Age)

Name of adult, teen or child at risk to abuse, or suspected (if known):

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(Name)

Time of day:

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Describe activity and people involved (e.g., nap time with siblings, games at
family picnic):

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Describe behaviors as specifically as you can (e.g., what you saw and heard):

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Note when you first noticed the behavior, how often you have seen it, and
why you are concerned:

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Note anything you said, or did and what happened:

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