JLFA-E - Suspected Child Sexual Abuse Report Form

JLFA-E - Suspected Child Sexual Abuse 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 child abuse? ___________________________________________

  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):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

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)

 

Cross Reference: JLF - Reporting Child Abuse and Neglect

JLF-R –Reporting Child Abuse and Neglect AdministrativeProcedure

JLF-E Suspected Child Abuse and Neglect Report Form

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: November 17, 2021