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JLF-E - Child Abuse Form

(Confidential)SUSPECTED CHILD ABUSE/NEGLECT REPORT FORM CONFIDENTIAL

AAny 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 follow-upconfirmation onwithin 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.

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

  2. Date and time of notifying person’s report: _________________________________

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

  4. Did notifying person contact DHHS independently: _____ Yes _____ No

  5. 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): __________________________________________________

  6. 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): ___________________________________________________________

  7. List any phonephotographs reportstaken or other materials collected related to DHSthe mustreport:

  8. 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 andor the SuperintendentDA of Schools within 48 hours ofby 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:_____________________________________________________________________________

______________________________________________________________________________________________

Description of Complaint: ________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Other pertinent information (history, previous reports, or concerns, etc.) ____________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

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 Designeeother _____________________________________________________Designated Agent.

Notifying Person/Original Reporter’s Signature Date and Time (Employee’s Signature)

Original: Principal Copy: Superintendent

Blue: Superintendent (Sealed and Marked "Confidential")

Pink: Department of Human Services

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