PGH Form No.

Q-660004 PHILIPPINE GENERAL HOSPITAL

The National University Hospital
University of the Philippines Manila
CHILD PROTECTION UNIT

I NTERVIEW
 526-8418
Taft Avenue, Manila
PHIC–Accredited Health Care Provider
ISO 9001:2008 Certified

Patient’s name  M  F CPU case #

DOB and age Born / / ________ years old  Physician
Date  Social Worker:
 NBI  PNP  Other _________________
Interviewed before by  Historian: Relation to Child:
 CPU has statement  None
Deferring interview?  child upset  not disclosing  previous statement taken by:  NBI  PNP  DSWD  Other:

 Other observers of interview:

 DISCLOSURE OF ABUSE
 physical
 sexual
 neglect
 BEHAVIORAL CHANGES
 depression
 blank stares, withdrawal
 nightmares, sleep disturbances
 loss of appetite
 suicide attempt, ideation
 truancy, problems at school
 
anxiety, hyperactivity
 running away from home
 aggression, anger
 self-mutilation
 psychotic episodes
 other: _____________
INCIDENT(S)
 Information from Historian  No Information Available
__________
Date of most recent incident / /
Other chronological Clues ___________________
Date of first abusive incident / /
Other chronological Clues ___________________
CHIEF COMPLAINT
 PHYSICAL COMPLAINTS  NEGLECT
 bruises  abandonment
 burns  dirty, unkempt
 fractures  undernourished
 cuts, wounds, lacerations  untreated medical problems
 poisoning  failing to thrive
 scars (healed injuries)
 delayed development
 unexplained injuries
 lack of supervision
 Dead on Arrival
 neglected schooling
 Seriously injured/dying
 other: __________________
 vaginal bleeding
vaginal/penile discharge
 Witnessed child abuse
 anogenital pain  Witnessed physical abuse
 anogenital injury  Witnessed sexual abuse
 sexual knowledge beyond age
 sexualized behavior
HISTORY OF ABUSE
DISCLOSURE
Time: ____________
Did the patient disclose?  Yes  No  N/A
 unknown
If yes,  voluntary  elicited
Time: ____________
 unknown Did the patient recant?  Yes  No  N/A

 Unknown To whom did child disclose first?

 female  male
Name: ____________________
 Single episode of abuse
 Multiple episodes over short time period. # of episodes: ___________
 mother  father  friend  physician
 Chronic abuse (greater than 6 months)  Unknown # of Episodes  sister  brother  neighbor  cousin
 aunt  uncle  teacher  socialworker
Estimated duration of Abuse:  1 - 7 days  1 wk – 2 months  grandmother  grandfather  classmate  other______
 2 – 6 months  > 6 months  Unknown duration
Site of abuse  known  unknown
Describe circumstances surrounding the initial disclosure:
 child’s home  school Witnessed?  Yes  No
 perpetrator’s  public place Witness _____________________
 Other: ___________________
Relation to child _______________
Address__________________
Specific site _______________ Philippine General Hospital  Child Protection Unit   526-8418 Page 1
 ACTS DESCRIBED BY THE CHILD AND/OR A HISTORIAN
 No disclosure by child to CPU  Relying on child’s previous disclosure to ___________________  Historian has no information
Please Check the Appropriate Box
 Sworn   Sworn Location of
Described by  Child  Historian Described by  Historian
Statement Child Statement injury
SEXUAL ABUSE PHYSICAL ABUSE
Penis / vagina Hand
Genital contact w/

Finger Fist
Foreign object Belt, cord, or stick

Hit with
Knife, blade
Describe the object Household tool
_______________
Penis Other, describe
Anal contact w/

Finger Cigarette

Burned With
Foreign object Flat iron
Hot liquid
Describe object
Other, describe
Oral copulation of genitals Biting
of victim by assailant Pinching
of assailant by victim Kicking
Masturbation Pulling hair
of assailant by self Slapping face
of assailant by victim Banging head
Ejaculation Violent shaking
specify location Dragged
Licking or kissing Describe other physical abuse
specify location
Fondling NEGLECT
specify location Underfed, unfed
Exhibitionism Unattended med. problems
Photos / videos taken / shown Accidental toxic ingestion
Force or weapon used Constantly unsupervised
Describe force / weapon Neglected schooling
Verbal threats Incomplete immunization
Given substance to change
Neglected schooling
consciousness
Intoxicated/Drunk Other
Unconscious/asleep EMOTIONAL ABUSE
Child is a sex worker Insulting, cursing, belittling
Threatening/Terrorizing
Describe other sexual abuse:
Other

Philippine General Hospital  Child Protection Unit   526-8418 Page 2

 CHILD’S BEHAVIOR DURING THE INTERVIEW
Cooperative Appropriate affect Describe child’s behavior and interaction with interviewer/caretaker:
Crying, very upset Depressed affect Caretaker present during interview?  Yes  No
Clinging to caretaker Flat affect, blank stares
Responsive to most questions Psychotic symptoms
Silent, unresponsive Combative, hostile
Able to narrate incident Hyperactive, anxious
Unable to narrate incident Short attention span

SUMMARY OF INTERVIEW

 Write down what the child says, using his or her actual words whenever possible.
 Verbatim comments are often very revealing when assessing a child’s disclosure.

Date: Time: Date: Time:

Place: Place:

Alleged Perpetrator: Alleged Perpetrator:

Phrases used to describe acts: Phrases used to describe acts:

Philippine General Hospital  Child Protection Unit   526-8418 Page 3

 DEVELOPMENTAL SCREENING
 Further Developmental assessment needed
 Probable developmental delay (for age below 7)
 Probable Learning problems (for school-aged)
 Physical disabilities
 Sensory impairment
 Neglected schooling
 Probable moderate to profound mental retardation
 Other________________________________
ALLEGED PERPETRATOR (S)
 Single perpetrator  Multiple perpetrators, one incident  Multiple perpetrators, separate incidents

ALLEGED PERPETRATOR 1 Identity  known  unknown  male  female

Full name & nickname Age _____ (yrs)  minor  unknown age
 mother  father  babysitter
 mother’s partner  father’s partner
Relationship to child  paternal  sister  teacher
 maternal
grandmother  brother  neighbor
 person known to child grandmother  paternal  friend  other
 stranger  maternal grandfather
 paternal aunt  pimp ______________
grandfather
 maternal aunt  paternal uncle

Current location of alleged perp  maternal

Alleged perpetrator’s
address/location
History of Substance Abuse
History of violence?
Criminal History?
 patient’s uncle
household  in jail, police custody  unknown  other known location _________________
 Alcohol  Drugs: _____________  Other substance: ______________  Unknown
 spouse  witnessed
 abused as a child  abused as a spouse abuser  unknown
family violence
 Previous conviction for similar offense  Previous conviction for other offense  Unknown
 Previous police blotter/barangay report for ______________

Occupation

ALLEGED PERPETRATOR(S)
ALLEGED PERPETRATOR 2 Identity  known  unknown  male  female

Full name & nickname
Relationship to child
Current location of alleged perp
Alleged perpetrator’s
address/location
History of Substance Abuse
History of violence?
Criminal History?
Age _____ (yrs)  minor  unknown age
 mother  father  babysitter
 mother’s partner  father’s  sister  teacher
 maternal partner
 paternal  brother  neighbor
grandmother
grandmother  friend  other
 maternal  paternal
grandfather  pimp ______________
grandfather
 maternal aunt  paternal
 maternal
 patient’s uncle
household aunt
 in jail, police custody  unknown  other known location _________________
 Alcohol  Drugs: _____________  Other substance: ______________  Unknown
 spouse  witnessed
 abused as a child  abused as a spouse abuser  unknown
family violence
 Previous conviction for similar offense  Previous conviction for other offense  Unknown
 Previous police blotter/barangay report for _____________

Occupation

Philippine General Hospital  Child Protection Unit   526-8418 Page 4