- Section J: Students
JLF-E - SUSPECTED CHILD ABUSE AND NEGLECT FORM
INSTRUCTIONS: Any school employee who suspects that a child has been or is likely to be abused or neglected (hereinafter referred to as the “notifying employee”) is required to immediately notify the building administrator (and may also directly report to DHHS, and the District Attorney if required). Please see Policy JLF for important definitions and requirements. This form should be completed by the person making the report to DHHS (and the District Attorney if required) -- generally the Superintendent or building administrator -- in consultation with the notifying employee. The completed form shall be provided to the notifying employee within 24 hours of his/her initial notification of the building administrator or Superintendent. The notifying employee shall sign the form acknowledging that he/she received confirmation that a report was made to DHHS, and the District Attorney if required. The report shall be forwarded to the Superintendent. The completed form shall be forwarded to DHHS, and the District Attorney if required (see Policy JLF), and filed for the required retention period. If the notifying employee does not receive a copy of this form confirming that a report was made within 24 hours of his/her original notification to the building administrator/Superintendent, he/she shall immediately make the abuse/neglect report to DHHS, and the District Attorney if required. The employee shall also ensure that this form is completed and filed with the Superintendent. |
SECTION 1 – INITIAL NOTIFICATION AND STUDENT INFORMATION
A. Name of notifying employee: _______________________________________
Position: _______________________________________________________
Contact information (telephone number/email address): __________________________________________________________________________________
B. Date, time and method of first notification: _____________________________
Building administrator notification made to (name/position): ______________________________________________________________________________
C. Did notifying employee make own telephone report to DHHS:
____ No ____ Yes DA: ___ No ___Yes
If yes, date, time and method of report(s)________________________________
Agency(ies) and name(s) of person(s) reported to: _________________________
D. Information about student:
Name: _____________________________________________________
School, grade and homeroom: ___________________________________
Age and gender of child: _______________________________________
Parent/guardian name(s): ______________________________________
Home address and telephone number: _____________________________
Names, school, grade and homeroom of any siblings: __________________
_____________________________________________________________
Any past evidence of abuse or neglect of student and/or siblings: ___ No ___ Yes
If yes, describe: ____________________________________________________________________________________________________________________________________________________________________
E. Description of alleged abuse or neglect, including injuries or other indicators, and any explanations provided for them: __________________________________
________________________________________________________________
Alleged perpetrator of abuse or neglect: ________________________________
________________________________________________________________
F. Any actions taken by school staff (aside from reporting abuse/neglect) (include
names, dates and times): ____________________________________________
________________________________________________________________
G. Any evidence collected (such as photographs, clothing or other items):
________________________________________________________________
H. Any other relevant information not included above: ______________________
________________________________________________________________
SECTION 2 – REPORTS TO SUPERINTENDENT, DHHS, AND DISTRICT ATTORNEY IF REQUIRED
A. Name and position of building administrator making report to Superintendent:
_________________________________________________________________
Date, time and method of report:_______________________________________
B. Name and position of administrator making report to DHHS, and District
Attorney if required: ________________________________________________
Date, time and method of telephone report to DHHS:______________________
Name of person taking report: _________________________________________
Date, time and method of telephone report to District Attorney (if required):
_________________________________________________________________
Name of person taking report: _________________________________________
C. Name of person sending form to DHHS, and District Attorney if required:
__________________________________________________________________
Date and method of sending form: _____________________________________
Report sent to DHHS: ___ Yes ___ No
Report sent to DA (if required): ___ Yes ___ No
SECTION 3 – CONFIRMATION GIVEN TO NOTIFYING EMPLOYEE THAT REPORT WAS MADE TO DHHS, AND DISTRICT ATTORNEY IF REQUIRED
The building administrator or Superintendent who made the report to DHHS, and the District Attorney if required, must provide written confirmation to the notifying employee within 24 hours of his/her initial notification.
A. Person providing completed form to notifying employee: __________________
B. Date, time and method of providing form to notifying employee:
________________________________________________________________
SECTION 4 – NOTIFYING EMPLOYEE ACKNOWLEDGMENT
The notifying employee must provide written acknowledgement that he/she received confirmation of a report being made to DHHS, and the District Attorney if required. If such confirmation is not received within 24 hours of the initial report, the notifying employee must make his/her own report to DHHS, and the District Attorney if required. In such a circumstance, the notifying employee should ensure that this form is completed.
I, _______________________, acknowledge that I have received the confirmation above that the required report has been made to DHHS, and the District Attorney if required.
_________________________________ _____________________________
Signature Date
ONCE THIS FORM IS COMPLETED IN FULL, RETURN IT TO THE SUPERINTENDENT’S OFFICE FOR FILING.
- Section J