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