JLF-E Suspected Child Abuse/Neglect Report Form
NEPN/NSBA Code: JLF-E 

SUSPECTED CHILD ABUSE/NEGLECT REPORT FORM 

Part A – To be filled out by staff person making report.

1) Date and time of first report: _____________________________________________

2) Name/title of school department official first report made to: ___________________________________________________

3) Name/title/telephone number of person(s) making first report: _________________________________________________

4) Name of student(s) who is subject of report: _________________________________

Birthdate: __________________ Sex: _____________ Grade: _______________

Known history of abuse/neglect? _____Yes _____ No

Explain:______________________________________________________________________________________________ _____________________________________________________________________________________________________

Parent/Guardian Name(s): _______________________________________________

Address: _____________________________________________________________

Home and work telephone numbers: _______________________________________

Name(s) of sibling(s) & DOB:_____________________________________________


5) 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): _________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

6) List any photographs taken or other materials collected related to the report: ____________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

Part B – To be filled out by School Counselor/Principal.


7) Did the person making first report contact DHS independently: _____Yes _____ No

8) Actions taken by school officials (list date, time and personnel involved): _______________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

9) 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): _______________________________________________________
___________________________________________________________________________________________________

10) Date/time report made/sent to Administration:

Principal: _________/__________

Superintendent: _________/__________

____________________________________________ __________________
Signature and title of person completing form Date

Revised: May 11, 2015 


M.S.A.D. #4