JLF-E - Suspected Child Abuse Neglect Report Form

SUSPECTED CHILD ABUSE/NEGLECT REPORT FORM

Any employee of Acton School Department who suspects that a child has been or is likely to be abused or neglected (the “notifying person”) must immediately notify the Superintendent/ Principal using this form.  The purpose of this form is to document your reporting and to facilitate confirmation to you that the Superintendent / Principal has made your report to the Department of Health and Human Services (DHHS) or, as appropriate to law enforcement.  

If you have not received written confirmation within 24 hours of submitting this form to the Superintendent / Principal, you must make your own report to DHHS or, if appropriate, to law enforcement.

This form is for school use only.  It is not to be sent to DHHS.

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 Superintendent/Principal first report made to:    ____________________________________________________________________

4) Did notifying person contact DHHS 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, cellular 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 Superintendent/Principal’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):  ________________________

  _____________________________________________________________________

 _________________________________   __________________

 Superintendent/Principal Signature    Date and Time

EMPLOYEE’S ACKNOWLEDGEMENT OF RECEIPT OF CONFIRMATION

(To be returned to Superintendent/Principal)

I have received confirmation that my report has been made to DHHS or to law enforcement by the Superintendent/Principal.

______________________________________   __________________

Notifying Person/Original Reporter’s Signature    Date and Time

(Employee’s Signature)

Adopted:   December 11, 2018