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”employee”) must immediately notify the building principaladministrator using this form. The purpose of this form is to document your reporting to the school unit and to facilitate confirmation to youconfirm that thea building principal or other designated school officialreport has been made your report to the Department of Health and Human Services (DHHS)DHHS. or, as appropriate to the District Attorney.
IfDHHS youmust havebe not received written confirmationnotified within 24twenty-four (24) hours of submittingwhen thisyou 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 thebe building principal, you must make your own reportsent to DHHS or,unless if appropriate, to the DA.requested.
1) Name/title/telephone number and email address of notifying personemployee (personemployee who originally haslearned of the information and is required to report it):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2) Date and time notifying employee learned of notifyingthe person’sinformation they are required to report: ___________________________________________________________________________________________________________________________
3) Name/title of schoolbuilding principaladministrator /designated agent notifying employee first report madereported to:
______________________________________________________________________________________________________________________________________________________________________________________________________
4) Name/title of employees who made the report to DHHS:
__________________________________________________________________________________________
5) Date and time of DHHS report:
__________________________________________________________________________________________
6) Did notifying personemployee contact DHS independently: _____ Yes _____ No
5)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): __________________________________________________
6)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):
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7)9) List any photographs taken or other materials collected related to the report:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
8)10) Actions taken by school personnel (list date, time and personnel involved):
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CrossPolicy Reference: JLF - Reporting Child Abuse and NeglectAdopted:
JLF-R –Reporting Child Abuse and Neglect AdministrativeProcedureJLFA - Child Sexual Abuse Prevention and ResponseJLFA-R - Child Sexual Abuse Prevention and Response ProcedureJLFA-E - Suspected Child Sexual Abuse Report Form
Policy Adopted:
Policy Reviewed: April 25, 2018
Policy Revised: November 17, 20212021; October 21, 2026
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 principaladministrator or designated agent)
I have received confirmation that myMy report has beenwas made to DHHS orwithin thetwenty-four DA(24) byhours theof Principalmy acquiring knowledge of potential child abuse or other Designated Agent.neglect.
____________________________________________________________________________________ _____________________________________________
Notifying Person/Original Reporter’Employee’s Signature Date and Time
(Employee’s Signature)_______________________________________________________
Reviewed: April 25, 2018