Procedure for Reporting Suspected Child Abuse

Participant ID #: ___________________ Date: ___________ Online or in-person: ________________

PLAN OF ACTION: CHILDHOOD ABUSE

CRITICAL INCIDENT PROCEDURE (CIP) FOLLOW-UP

[1] DISCLOSURE SCRIPT and FOLLOW-UP QUESTIONS TO ASSESS LEVEL OF RISK

Interviewer Script: “At the beginning of this project you signed a consent form (in-person or electronically) saying that you understand your responses will be kept confidential. However, I am worried about your safety, and if you remember, the consent form indicated that I may need to report any situations in which you may be in danger. I would appreciate your honesty in helping me understand how we can help.

You indicated (in person or online) that you may be experiencing physical and/or sexual abuse or have in the past. These might be things like:

• You were forced to have sex with someone when you didn’t want to.

• A sexual partner punched, slapped, or hurt you.

• You had sexual contact with an adult

• A parent or caretaker punched, slapped or hurt you.

I know this might be uncomfortable, but I am going to ask you to answer a few questions pertaining to the event or events you reported (in person or online). You don’t need to tell me the specifics, just the basics to help me determine that you are safe.”

1) “Did the experience you mentioned happen recently (in the past 4 months) or is it something that happened before you began this study?”

Abuse Indicated, and ongoing. Continue to Question 2.

Abuse Indicated, but in the past. Continue to Question 2.

No Abuse Indicated. GO TO QUESTION 5.

2) Interviewer Script: “Do you still see this person? If so, how much time do you spend around this person?” ____________________________________________________________________________________________________________________________________________________________________________________
“Yes”, Flagged for Imminent Risk

3) Interviewer Script: “What was/is this person’s relationship to you?”

[Flag for IMMINENT RISK if participant indicates that the person is a parent, stepparent, significant other of parent, guardian, foster parent, family member, teacher, therapist who is in contact with the participant]

____________________________________________________________________________________________________________________________________________________________________________________

Flagged for Imminent Risk (if any of the relationships listed above)

4) Interviewer Script: “Do you currently feel safe?”

Yes, Skip to Question 5

No, continue to Question 4a “No”, Flagged for Imminent Risk and continue to 4a

4a) “Why don’t you feel safe?” OR “Do you think you can stay safe tonight?”
________________________________________________________________________________________________________________________________________________________________________

5) Interviewer Script: “Do you feel upset now that we have talked about this?”

_______________________________________________________________________________________

“Very Upset”: Flagged for Imminent Risk

[2] ASSESSMENT OF RISK & ABUSE

• SITUATION #2: NO IMMINENT RISK & ABUSE INDICATED

1. Interview Script: “Based on your responses, I want to make sure you’re safe. We have a great team of clinicians that I’d like to check in with and possibly invite to speak with you. Would you be OK with that?”

2. Immediately Contact PI: Inform her/him that there is a participant who has experienced abuse.

3. Senior Study Staff Assists with Contacting On-Call Clinician for Evaluation: Senior study staff will determine if on-call clinician should be contacted.

4. Follow Up:

Option A: Clinician Doesn’t Evaluate Participant: Complete page 3 with participant (e.g. determine available support, provide referrals, write up plan of action, etc.). Finalize CIP form, complete safety log and route to supervisor within 24 hours.

Option B. Clinician Provides Further Evaluation: Allow clinician to further assess risk and work with clinician to complete page 3 (e.g. determine support, provide referrals, write up plan of action, etc.). Finalize CIP form, complete safety log and route to supervisor within 24 hours.

***If deemed necessary by clinician AND reviewed with the PI:

• Work with PI, clinician and supervisor to fill out DCF reporting form

• Make copy of written confirmation form and send original to DCF

• SITUATION #1: ABUSE NOT INDICATED

1. Interviewer Script: “It seems like you’re not in any immediate danger and that you’re feeling OK now that we’ve talked about this. Experiences like these can be very difficult to cope with, so it can be a good idea to talk with a therapist or others about these experiences if you ever need support or someone to talk to.”

2. Supportive Referrals: Give participant referrals (see attached referrals sheet) and discuss plan of action.

3. Post-interview: Write-up the Plan of Action (page 3), complete safety log and route to the supervisor within 24 hours.

• SITUATION #3: IMMINENT RISK & ABUSE INDICATED

1. Interview Script: “Based on your responses, I want to make sure you’re safe. We have a great team of clinicians that I’d like to check in with and possibly invite to speak with you. Would you be OK with that?”

2. Immediately Contact PI: Inform her/him that there is a participant who is at IMMINENT RISK.

3. Senior Study Staff Assists with Contacting On-Call Clinician for Evaluation: Senior study staff will follow safety event SSP for contacting emergency on call clinician.

4. Follow Up:

Option A: Clinician Doesn’t Evaluate Participant: Complete page 3 with participant (e.g. determine available support, provide referrals, write up plan of action, etc.). Finalize CIP form, complete safety log and route to supervisor within 24 hours.

Option B. Clinician Provides Further Evaluation: Allow clinician to further assess risk and work with clinician to complete page 3 (e.g. determine support, provide referrals, write up plan of action, etc.). Finalize CIP form, complete safety log and route to supervisor within 24 hours.

***If deemed necessary by clinician AND reviewed with the PI:

• Work with PI, clinician and supervisor to fill out DCF reporting form

• Make copy of written confirmation form and send original to DCF

[3] PLAN OF ACTION: CHILDHOOD ABUSE

A. Interviewer/Clinician Script: Do you currently have a therapist? If so, do you feel you can talk about these things with your therapist?

____________________________________________________________________________________________________________________________________________________________________________________

B. Interviewer/Clinician Script: Would you be interested in any legal resources or other referrals?

____________________________________________________________________________________________________________________________________________________________________________________

C. Plan of Action (developed with participant by clinician or interviewer):¹

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

Post-Visit: Summarize Risk Assessment (clarify the risk(s) and how you determined the level of risk):²

If clinician called in, this should be completed by clinician, otherwise it should be completed by interviewer.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

[write on the back of the pages if necessary]

__________________________________ __________________________

Signature of Assessor Date

(Sign on day of CIP)

_________________________ ___________________________

Signature of Clinician-on-call Date

(Imminent Risk or if consulted)

__________________________ ____________________________

Signature of Principal Investigator or Co-Investigator Date

(Imminent Risk or if consulted)

Appendix 1: Checklist for Mandated Reporters

When DCF is called, the operator will ask you for the following information. Please prepare this information BEFORE placing a call to DCF. If you do not have all of the information requested on this form, or if the participant does not want to disclose this information, indicate to the operator that you do not have the information.

I. Alleged Victim(s)

Name(s) of victim(s): ________________________________________________________________

Birthdate(s) of victim(s) or approximate age: ______________________________________________

Address (or approximate address): ______________________________________________________

__________________________________________________________________________________

II. Alleged Perpetrator(s)

Name(s): _____________________________________________________________________________

Birthdate(s) or Age(s) or some approximation so role of DCF can be determined: __________________

Relationship to Victim(s): _______________________________________________________________

Address: _____________________________________________________________________________

_____________________________________________________________________________________

III. Harms to Victim(s)

• Physical Abuse

• Sexual Abuse

• Risk of Harm

• Neglect

• Death

NOTE: The Hotline worker will be able to put the allegation in the proper sub-category such as

Physical Abuse/Cuts, Bruises, and Welts.

IV. Description of Incident(s)

Be prepared to give a brief description of the incident(s) of abuse. This description should include:

1. as much detail as you have about the actual incident

2. indication of intention (especially in physical abuse)

3. description of the time and place of the incident

4. information, if any, about possible witnesses to the abuse

5. evidence of abuse (physical evidence, behavioral indicators, disclosure by the victim, etc.)

Violence Recovery Program at Fenway Health

Support groups for GLBT individuals, providing support in areas and on issues such as recovery, coming out, trauma, self-esteem, parenting, and substance abuse.

Phone: 617-927-6250

Toll-Free: 800-834-3242 www.fenwayhealth.org/vrp

The Boston Area Rape Crisis Center (BARCC)

24-hour hotline: 800-841-8371

http://www.barcc.org/

Center for Hope and Healing

Offers free counseling, referrals, support groups and advocacy for all survivors of sexual assault/abuse, rape, and incest.

Lowell, MA

Phone: 978-452-7721

24-Hour toll-free hotline 800-542-5212

http://www.rcsglinc.org/

Dove, Inc.

24 Crisis Hotline, community services, support groups, legal advocacy, 911 cell phones, sexual assault services and referrals.

Quincy, MA

24-hour line: 617-471-1234, 888-314-3683

Outreach & Family Services: 617-770-4065

http://www.doveinc.info/

The Network/La Red

Offers free direct services for abused LBT individuals, including emergency shelter, support groups, safety planning, court accompaniment, information, and referrals and accessing social, legal, medical, housing services. All services are in English/Spanish, wheelchair- and TTY accessible. ASL interpreters and childcare available.

Boston, MA

Hotline: 617-742-4911; TTY for the hearing impaired: 617-227-4911; Tel: 617-695-0877

E-mail: [email protected]; http://tnlr.org/

Renewal House

Provides advocacy, and support groups, help with public assistance and referrals for financial assistance, legal services, job training and education, counseling, health/dental, and childcare.

Phone: 617-566-6881

http://www.uuum.org/567026

RESPOND, Inc.
Provides life-saving shelter, support services, training and education. Services are free and confidential and available to all survivors of domestic abuse.

24-hour hotline: 617-623-5900

http://www.respondinc.org/Home.aspx

Victim Rights Law Center (VRLC)

Offers free legal assistance to victims of sexual assault in privacy, education, immigration, employment, public benefits, housing and safety.

115 Broad Street, 3rd Floor

Boston, MA 02110

Phone: 617-399-6720

www.victimrights.org

Healing Abuse Working for Change

HAWC offers support groups, legal advocacy, children’s services, a shelter, community education. They offer services in English, Spanish, Portuguese

27 Congress Street

Salem, MA

Phone: 978-744-2999 x17 (Salem)

978-283-8642 (Gloucester)

781-592-9900 (Lynn)

http://hawcdv.org

The Boston Fair Housing Commission

Responds to Housing Discrimination
Boston City Hall, Boston, MA 02201
Phone: 617-635-4408

http://www.bostonfairhousing.org/What-We-Do.html

Melody Bravo, Citywide GLBT Family Liaison

Cambridge Public Schools

Phone: 617-349-6727

Community Legal Services & Counseling Ctr

Legal assistance & mental health counseling

1 West Street, Cambridge, MA 02139
Phone: 617-661-1010

Gay and Lesbian Advocates and Defenders (GLAD)
Legal rights organization dedicated to ending GLBT and HIV discrimination.

294 Washington Street; Suite 740

Boston, MA 02108

Phone: 617-426-1350

www.glad.org

Greater Boston Legal Services
197 Friend Street, Boston, MA 02114
Phone: 617-371-1234

Harvard Law School Legal Services Center

617.522.3003

www.law.harvard.edu/academics/clinical/lsc/help

HIV/AIDS Law Consortium of Western Massachusetts

800.633.1890 or 413.732.0011

www.hivaidslawconsortium.org

JRI Health Law Institute

Boston, MA

Phone: 617-988-8700

www.jri.org

Massachusetts Commission Against Discrimination (MCAD)

MCAD is the state's chief civil rights agency. MCAD works to eliminate discrimination and advance civil rights. If you believe you have been discriminated against, you should file a complaint with the MCAD immediately. 

Hours: 8:45 am - 4:00 pm

Phone: Boston 617-994-6000


Springfield 413-739-2145 Worcester 508-799-8010

New Bedford 508-990-2390

TransCEND Legal service/AIDS Action

75 Amory Street, Jamaica Plain, MA 02119
Phone: 617-437-6200

Walk in (Tues.Wed.Thurs.)

www.aac.org

Lawyers Committee for Civil Rights
294 Washington Street
Boston, MA 02110
Phone: 617-482-1145

Samaritans Suicide Hot Line

Samaritans, Inc. is a non-denominational, not-for-profit volunteer organization serving greater Boston & Metro west communities. We are dedicated to reducing the incidence of suicide by befriending individuals in crisis and educating the community about effective prevention strategies. We reach more than 100,000 people each year with the help of more than 400 volunteers – 100 of them teens.

http://samaritanshope.org/

Samaritans state-wide toll free: 877-870-4673

Samaritans: 800-252-8336

24-Hour helplines: 617-247-0220 or 508-875-4500

MTPC Suicide Prevention for Transgender Persons

Two brochures are now available addressing the issue of transgender suicide. These may be downloaded via the links from the MTPC web site or from MTPC’s offices.

http://www.masstpc.org/publications/suicideprevention.shtml

Other Helplines:

Trevor Project: 866-488-7586 (866-4-U-TREVOR)

Gay, Lesbian, Bisexual and Transgender Helpline: 617-267-9001, Toll-free: 888-340-4520

P eer Listening Line: 617-267-2535; Toll-free: 800-399-PEER

Legacy Community Health Center
1415 California Street, Houston, TX 77006
Phone: 832-548-5000

The Montrose Center

401 Branard Street, Houston, TX 77006

Phone: 713-529-0037

Hatch Youth (at the Montrose Center)

401 Branard Street, Houston, TX 77006

Phone: 713-529-0037

*Phoenix Youth is a Hatch program specifically for youth of color

Texas Youth Hotline 24/7

Call: 1-800-989-6884

Text: 512-872-5777

PFLAG Houston

Phone: 713-467-3524

Texas Abuse/Neglect Hotline – Department of Family and Protective Services

Phone: 1-800-252-5400

Website: www.txabusehotline.org

The Attic Youth Center

255 South 16^th Street, Philadelphia, PA 19102

Phone: 215-545-4331

The Mazzoni Center – LGBTQ Health & Well-being

21 S. 12^th Street, 8^th Floor, Philadelphia, PA 19107

Phone: 215-563-0652

Legal services: 215-563-0657

PFLAG Philadelphia

Phone: 215-572-1833

Website: www.pflagphila.org

The Support Center for Child Advocates – LGBTQ Youth Project

1617 JFK Blvd, Suite 1200, Philadelphia, PA 19103

Phone: 267-546-9200

Y-HEP (Youth Health Empowerment Project)

1417 Locust Street, 3^rd Floor, Philadelphia, PA 19102

Phone: 215-564-6388

Gay and Lesbian Latino AIDS Education Initiative (GALAEI)

149 W. Susquehanna Ave, North Philadelphia, PA 19122

Phone: 267-457-3912

1 Specify: type of incident (e.g., slapped, raped), when the incident occurred, abuser (caregiver or non-caregiver), action taken (e.g., police report, informed family), current state of the participant (e.g., no abuse), and resources provided for support.

2 Summarize what the participant stated and clarify the current state of the incident (e.g., participant is not currently being abused).

CIP Script (Child Abuse) Page 3 of 4