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 employee”) must immediately notify the building administrator using this form. The purpose of this form is to document your reporting to the school unit and to confirm that a report has been made to the Department of Health and Human Services (DHHS. 
DHHS must be notified within twenty-four (24) hours of when you acquire knowledge of a potential child abuse or neglect. Notification may be made by you (in consultation with a designated agent and/or independently); or if you are unavailable, by a designated agent. This form is for school use only. It is not to be sent to DHHS unless requested.
1) Name/title/telephone number and email address of notifying employee (employee who originally learned of the information and is required to report it):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2) Date and time notifying employee learned of the information they are required to report: __________________________________________________________________________________________
3) Name/title of building administrator /designated agent notifying employee first reported to: 
__________________________________________________________________________________________
4) Name/title of employees who made the report to DHHS:
__________________________________________________________________________________________
5) Date and time of DHHS report:
__________________________________________________________________________________________
6)  Did notifying employee contact DHS independently: _____ Yes  _____ No
7) 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): __________________________________________________
8) 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): 
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9)  List any photographs taken or other materials collected related to the report:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
10) Actions taken by school personnel (list date, time and personnel involved):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Policy Adopted:
Policy Reviewed:  April 25, 2018
Policy Revised: November 17, 2021; October 21, 2026
 
EMPLOYEE’S ACKNOWLEDGEMENT OF RECEIPT OF CONFIRMATION
(To be returned to administrator or designated agent) 
My report was made to DHHS within twenty-four (24) hours of my acquiring knowledge of potential child abuse or neglect.
______________________________________________                        ___________________________
Notifying Employee’s Signature                                                                    Date and Time