Fillable LIC 9108


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What is LIC 9108 Form?

LIC 9108 is also known as the Statement Acknowledging Requirement to Report Child Abuse. This form was created and provided by the State of California Health and Human Services Agency. According to the local law in California, any citizen that notified possible child abuse has to report it to the authorities using the form. Even if it is a suspicion the document has to be filled in by the witness.

Normally the form is used by the member, an employee, or the licensee of the child care institution or special facility for children. These people are somehow related to the places that offer their services to children, whether they are administrators, employees, or licensees. They are called mandated reporters.

The reporter can use the form to report on child abuse in the institution that offers child care, as well as in the foster parents, residential care facilities, or families. The reporter is obliged to send the form to the officials. No one can make an order to the report about withholding the information.

Form LIC 9108 on PDFLiner

What I need the LIC 9108 Form for?

  • The LIC 9108 California document is required by the mandated reporter, the administrator, licensee, or employee that works in a child care institution, visits foster parents' houses, or received complaints from the witnesses of child abuse in the family. In this case, the person has to pay the visit to the facility, check out the situation, and provide the observation in the form;
  • This form is required by California officials. In case the abuse was reported even if it was just suspected, it must be investigated. Agency will have to act immediately if the observer will confirm the suspicion. The report must be sent within 36 hours after the abuse was noticed or suspected.

How to Fill Out LIC 9108 Form?

You can find the LIC 9108 form on PDFLiner. The form is free of charge and available for download. You can use it on your computer. Tools available on PDFLiner allow you to edit the form, complete it, or change it the way you need online. Once you complete the document, you may send it online to the department you need. If you prefer the classic way, you can easily print the form, sign it manually, and hand it to the person.

The document is 2 pages long. However, it is incredibly simple to fill. Mostly it contains explanations about the situation you are currently in and whether you need to contact authorities. Here is what you need to include in the document:

  1. Provide your own name, position, and the number of facilities you work at;
  2. Read all the instructions for your next actions in the situation and where to send the form;
  3. Write down your name in the acknowledgment of responsibility;
  4. Place your signature at the bottom of the document and write down the current date when you fill out the form.

Organizations that work with LIC 9108 Form

  • State of California Health and Human Services Agency.
Fillable online LIC 9108
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