JLF-E/MSAD #11 SUSPECTED CHILD ABUSE/NEGLECT REPORT FORM
File: JLF-E
MSAD #11 SUSPECTED CHILD ABUSE/NEGLECT REPORT FORM
1) Name/title/telephone number of person making first report: ____________________________________________________________________
2) Date and time of first report: ____________________________________________________________________
3) Name/title of school department official first report made to: _________________
____________________________________________________________________
4) Did the person making first report contact DHS independently: ____ Yes ____ No
5) Date/time/person making report to Superintendent: _________________________
6) 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): ________________________________________________
7) 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): __________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
File: JLF-E
8) List any photographs taken or other materials collected related to the report: ______
___________________________________________________________________
___________________________________________________________________
9) Actions taken by school officials (list date, time and personnel involved):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
10) Reports to authorities:
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):________________________ ___________________________________________________________________
Signature and title of person completing form:
____________________________________ ___________________________
Date: ______________________