Suspected Child Abuse/Neglect Report Form

NEPN/NSBA Code:  JLF-E

Any employee of the Yarmouth School Department 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.

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 principal /designated agent first report made to: 


4)      Did notifying person contact DHS 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 and work telephone numbers:

         Name(s) of sibling(s):


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

 

________________________________________________________________________(Employee’s Signature)                                                                   

___________________________________ Date and Time

 

 

Approved:  November 12, 2015

 




J - Students