Child Abuse Interview Questionnaire
1. Interviewer Information
Name
Date
Location
2. Child's Information
Name
Age
Gender
Female
Male
Other
3. Incident Details
Date of Incident
Location of Incident
Description of Incident
4. Persons Involved
Name(s) and relationship(s) to the child
5. Signs and Symptoms
Physical/behavioural signs observed
6. Statements from the Child
Child's own words (verbatim if possible)
7. Additional Notes
Other relevant information