JLF-E - Child Abuse Form

SUSPECTED CHILD ABUSE/NEGLECT REPORT FORM
CONFIDENTIAL
Any employee of Regional School Unit 1 who suspects that a child has been or is likely to be abused or neglected (the “notifying person”) must immediately notify the building principal using this form. The purpose of this form is to document your reporting and to facilitate confirmation to you that the building principal or other designated school official has made your report to the Department of Health and Human Services (DHHS) or, as appropriate to the District Attorney.
If you have not received written confirmation within 24 hours of submitting this form to the building principal, you must make your own report to DHHS or, if appropriate, to the DA.
This form is for school use only. It is not to be sent to DHHS.

Name/title/telephone number and email address of notifying person (person who originally has the information and is required to report it): ____________________________________________________________________

Date and time of notifying person’s report: _________________________________

Name/title of school principal /designated agent first report made to: 	____________________________________________________________________

Did notifying person contact DHHS independently: _____ Yes _____ No

Name of student who is subject of report: ___________________________________
Birthdate: __________________ Sex: _____________ Grade: _______________
Known history of abuse/neglect? __________________________________________
Parent/Guardian Name(s): _______________________________________________
Address: _____________________________________________________________
Home and work telephone numbers: _______________________________________
Name(s) of sibling(s): __________________________________________________

Statements or indicators leading to the suspicion of abuse/neglect (include all known
information, including date, time and location, name of alleged abuser, and relationship
to student): ___________________________________________________________

List any photographs taken or other materials collected related to the report:

Actions taken by school personnel (list date, time and personnel involved):

CONFIRMATION OF REPORT
(Used for confirming principal or designated agent’s report to authorities)
Name of principal or designated agent: ___________________________¬__________
Agency contacted by telephone: __________________________________________
Name and title of agency contact: _________________________________________
Date and time of telephone report: _________________________________________
Copy of report form sent (include date and addressee): ________________________
_____________________________________________________________________

______________________________			__________________
Principal/Designated Agent Signature			Date and Time

EMPLOYEE’S ACKNOWLEDGEMENT OF RECEIPT OF CONFIRMATION
(To be returned to principal or designated agent)
I have received confirmation that my report has been made to DHHS or the DA by the Principal or other Designated Agent.

Notifying Person/Original Reporter’s Signature			Date and Time
(Employee’s Signature)
Original: Principal
Copy: Superintendent