Confidential Notice of Concern

CONFIDENTIAL NOTICE OF CONCERN
This notice is used to report actual or suspected child sexual abuse, physical abuse, neglect, bullying, harassment, or other forms of abuse as described below. It is not meant to be used for general complaints about someone’s philosophies, mindset or general attitude. If your concern is not regarding one of the specified categories, please direct your concern to your parish, school, the Chancery or the appropriate office.
TYPE OF CONCERN
Please check all applicable boxes*

Sexual AbusePhysical AbuseNeglectBullyingHarassmentThreatsMental/Emotional abuseSex TraffickingOther
VICTIM(S)

Please enter as much information as you know about the victim.
Name of Victim*
Gender*

MaleFemale
Grade*
Date of Birth or Age*
Victim's Address*
Please enter full address (Street name, city, state, zip code)
Victim's School*
Relationship of victim to abuser*
Does victim have special needs?*
Additional victim(s) or possible victims?
Name(s) of victim's parents/custodians
Other household members
Alleged perpetrator of abuse/person responsible for harm
INCIDENT / ALLEGATION INFORMATION
Date & Time of Incident / Abuse*
Place of Incident / Abuse*
Please describe the circumstances of the abuse:
- What happened (If describing what you observed, describe as factually as possible. If based on victim’s disclosure, please use the victim’s words where possible to relate what happened)?
- Who was involved & who was present?
- If the victim is a child, are the child’s parents aware of the concern?
- Are there physical signs of abuse (e.g. bruises, injuries, etc.)?
- Do you know if the victim has been examined by a medical professional?
(Please enter as much information as you know)*
Did you take any action or speak with the victim about what happened?*
Are you aware of similar or past incidents involving the victim or alleged perpetrator?*

NoYes
If yes, please explain*
Was the past incident(s) reported to authorities?
Are you aware of a follow-up plan for the safety of the victim? Does anyone else need to be notified?*
MANDATED REPORTING LAWS IN TEXAS

Pursuant to Chapter 261 of the Texas Family Code ANY person who has cause to believe that a child has been or may be abused or neglected must make a report to Child Protective Services (CPS) or to any state or local law enforcement agency. Texas Abuse Hotline: 1-800-252-5400.
Has this concern been reported to Child Protective Services (CPS)?*

NoYes
If yes, date and time of report

MonthDayYear
DateHourMinutesAM/PM Option
Report #*
Has this concern been reported to a law enforcement agency?*

NoYes
If yes, date and time of report

MonthDayYear
DateHourMinutesAM/PM Option
Name of Agency and Report #*
REPORTER INFORMATION
Name of Reporting Party*
Title*
Contact / Telephone*
Email*
Address*
Please enter full address (Street name, city, state, zip code)
Signature of Reporter*
Date*

MonthDayYear
Date
Other witnesses (include anyone who may have knowledge or information about the incident) and their title
For questions, please contact Alma Garcia, agarcia@fwdioc.org or 817-945-9342.

Address: The Catholic Center, Catholic Diocese of Fort Worth, 800 West Loop 820 South, Fort Worth, TX 76108.
This notice may be shared with other departments or agencies for the limited purpose of conducting an investigation or to fulfill other requirements of the law.
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CONFIDENTIAL NOTICE OF CONCERN