Summary Data Component Survey Section 4

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OMB No. 0980-0229
Expiration Date: 05/31/00

SECTION 4. CHILD VICTIMS

4.1	Child Victims by Type of Maltreatment Enter the number of children who were found to be victims of maltreatment by type of maltreatment and disposition. One or more types of maltreatment can be recorded for each child victim.

		Substantiated		Indicated		In Need of Services
A.	Physical Abuse. Enter the number of victims of physical acts that caused or could have caused physical injury.	[	]	[	]	[	]
B.	Physical Abuse. Enter the number of victims of physical acts that caused or could have caused physical injury.	[	]	[	]	[	]
C.	Physical Abuse. Enter the number of victims of physical acts that caused or could have caused physical injury.	[	]	[	]	[	]
D.	Physical Abuse. Enter the number of victims of physical acts that caused or could have caused physical injury.	[	]	[	]	[	]
E.	Physical Abuse. Enter the number of victims of physical acts that caused or could have caused physical injury.	[	]	[	]	[	]
F.	Physical Abuse. Enter the number of victims of physical acts that caused or could have caused physical injury.	[	]	[	]	[	]
G.	Physical Abuse. Enter the number of victims of physical acts that caused or could have caused physical injury.	[	]	[	]	[	]
	TOTALS	[	]	[	]	[	]

4.2

Child Victims by Age

Enter the number of child victims by age at the time of the report or as of December 31 of the reporting year. If your State reports by age groups (e.g., 1-3, 4-6, etc.), please divide the number among the years in each group, putting the remainder into the oldest age in the group.

Age in Years	Number of Victims
<1	[	]
1	[	]
2	[	]
3	[	]
4	[	]
5	[	]
6	[	]
7	[	]
8	[	]
9	[	]
10	[	]
11	[	]
12	[	]
13	[	]
14	[	]
15	[	]
16	[	]
17	[	]
18 and older	[	]
Unknown	[	]
TOTAL	[	]

4.3	Child Victims by Sex Enter the number of child victims by sex.
A.	Male	[	]
B.	Female	[	]
C.	Unknown	[	]
	TOTAL	[	]

4.4	Child Victims by Hispanic or Latino Ethnicity Enter the number of child victims by Hispanic or Latino ethnicity.
A.	Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.	[	]
B.	Not Hispanic or Latino.	[	]
C.	Unable to Determine or Unknown. The child victim is very young or is severely disabled and no other person is available to identify ethnicity, or the child victim's ethnicity was not recorded.	[	]

4.5	Child Victims by Race Enter the number of child victims by race. A child victim may be counted in more than one racial group.
A.	African American. A child having origins in any of the black racial groups of Africa.	[	]
B.	American Indian or Alaska Native. A child having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.	[	]
C.	Asian. A child having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.	[	]
D.	Native Hawaiian or Other Pacific Islander. A child having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.	[	]
E.	White. A child having origins in any of the original peoples of Europe, the Middle East, or North Africa.	[	]
F.	Other. A child having other or multi-racial origins, who has not been counted above.	[	]
G.	Unable to Determine or Unknown. The child victim is very young or is severely disabled and no other person is available to identify race, or the child victim's race was not recorded.	[	]
	TOTAL	[	]

4.6	Child Victims Whose Families Received Family Preservation Services in the Previous Five Years
	Enter the number of child victims whose families had received Family Preservation Services during the five (5) years preceding the report(s) of child abuse or neglect received in this reporting period. Family Preservation Services are services designed to protect children from harm and to assist families at risk or in crisis, including services to prevent placement, to support the reunification of children with their families, or to support the continued placement of children in adoptive homes or other permanent living arrangements.	[	]

4.7	Child Victims Who Were Reunited with Their Families in the Previous Five Years
	Enter the number of child victims who were abused by the parents or principal caretakers with whom they had been reunited in the previous five years.	[	]

4.8	Child Victims for Whom Court Action Was Taken
	Enter the number of child victims for whom court action was initiated either during or as an immediate result of an investigation. Court action is legal action initiated by a representative of the CPS agency on behalf of the child. This includes, for instance, authorization to place the child, filing for temporary custody, dependency, or termination of parental rights. It does not include criminal proceedings against a perpetrator.	[	]

4.9	Child Victims Who Received Court-Appointed Representatives
	Enter the number of child victims for whom an individual (guardian ad litem) was appointed by the court to represent the best interests of the child. A guardian ad litem may be an attorney, a court-appointed special advocate, or both.	[	]

4.10	Average Number of Out-of-Court Contacts Between the Court-Appointed Representatives and the Child Victims They Represent
	Enter the average number of out-of-court contacts which enable the court-appointed representatives to obtain first-hand an understanding of the situation and needs of the child victim, and to make recommendations to the court concerning the best interests of the child.	[	]