Enclosure (1) to COMDTINST 1754.12
OTHER PROFESSIONALS INVOLVED:
NAME
AGENCY
POSITION or TITLE
PHONE #
ALLEGATIONS/REASON FOR REFERRAL:
On
(date) at
(time), the ISC
Family Program
Administrator,
, was contacted by
. The reporter
(Name) was/was not promised confidentiality. The reporter, Name,
alleged ........................................
FINDINGS AND INVESTIGATIVE RESULTS:
Contact with or regarding child/spouse victim. Give dates, places, how obtained (phone, in
person), pertinent information gained. How this relates to dynamics of abuse and/or neglect.
Contact with or regarding parents, spouse, abuser. Give dates, places, how obtained (phone, in
person), pertinent information gained, and how related to the dynamics of abuse and/or neglect.
Contact with or regarding siblings and other immediate family members. Give dates, places,
how obtained (phone, in person), pertinent information gained, and how related to the dynamics
of abuse and/or neglect.
Case-related contact with CO, XO, OINC, XPO, or command representative. Give dates,
places, how obtained (phone, in person), pertinent information gained.
Case-related contact with G-WPW-2 Program Managers. Give dates, places, how obtained
(phone, in person), pertinent information gained.
Collateral contacts, including the complainant, other professionals, relatives, doctors, police.
Give dates, how obtained (phone, in person).
Information and results of CPS investigation, civilian law enforcement, CGI, civil and/or
criminal court hearings, orders, actions, and outcomes.
Any social history obtained which seems pertinent to the determination of abuse and/or neglect.
What, if any, support system exists for this family?
Include in the dictation any releases of information you received, from whom, when, etc.
THE DICTATION IN THIS SECTION MUST PROVIDE THE BASIS FOR YOUR
FINAL CASE STATUS DETERMINATION OF SUBSTANTIATED.
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