JLF-E:   SUSPECTED CHILD ABUSE & NEGLECT REPORT FORM

Any employee of Kittery School District 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.

The 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 first report:

3.  Name/title of school district official first report made to:

4. Did notifying person contact DHS independently: (circle one). 

                      Yes                             No

5.  Name of student who is subject of report:

Birthdate:

Grade:

Name(s) of sibling(s):

Parent/Guardian Name(s):

Address:

Home & work telephone numbers:

Known history of abuse/neglect:

6.  Statements or indicators leading to the suspicion of abuse/neglect (include all know 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):

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: