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JLF-E - Suspected Child Abuse/Neglect Report Form

JLF-E - Suspected Child Abuse/Neglect Report Form

Any employee of MSAD #35 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.

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 DHS 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 photographs taken or other materials collected related to the report:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Cross Reference: JLF - Reporting Child Abuse and Neglect

JLF-R –Reporting Child Abuse and Neglect AdministrativeProcedure
JLFA - Child Sexual Abuse Prevention and Response
JLFA-R - Child Sexual Abuse Prevention and Response Procedure
JLFA-E - Suspected Child Sexual Abuse Report Form

Policy Adopted:

Policy Reviewed:  April 25, 2018

Policy Revised: November 17, 2021




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)_______________________________________________________

Reviewed:  April 25, 2018

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