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