JLF-E - Child Abuse Form
(Confidential)
A written follow-up on any phone reports to DHS must be made to DHHS and the Superintendent of Schools within 48 hours of the initial report to DHHS.
Child's Name: _______________________________ Phone: ____________________________________
Address ____________________________________ DOB: ____________________________________
____________________________________ Sex: _____________________________________
Mother's Name:______________________________ Father's Name: _____________________________
With Whom Does Child Reside: ____________________________________________________________________
Family Composition:_____________________________________________________________________________
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Description of Complaint: ________________________________________________________________________
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______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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Other pertinent information (history, previous reports, or concerns, etc.) ____________________________________
______________________________________________________________________________________________
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Source of Report to Principal: ________________________________________ Phone: ______________________
Occupation/Relationship to Child: __________________________________________________________________
Actions Taken By: Principal - Designee: (Please Circle) (Name): _________________________________________
DHS - Name of Contact: ___________________________________________ Date: _______________________
Superintendent - Name of Contact: ___________________________________ Date: ________________________
Signature of Principal or Designee _____________________________________________________
Original: Principal
Blue: Superintendent (Sealed and Marked "Confidential")
Pink: Department of Human Services