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JLF-E

Maine School Administrative District No. 31

Child Abuse and Neglect Mandated Reporter Form


Mandated Reporter:

The following is information that will be requested/required at the time a report is made to Child Protective Intake (DHHS). The more information you have available, the clearer the decision regarding their response. This report is to be filled out by the staff member calling in a report; a copy of the completed report must be given to the building administrator.


  • If the alleged perpetrator is the parent and/or guardian or lives in the home, the report is filed with DHHS. The intake number is 1-800-452-1999 fax:287-5065

  • If the alleged perpetrator lives outside of the home and is NOT a guardian, the District Attorney’s Office is to be called: Piscataquis County: 564-2181 Penobscot County: 942-8552


Name of the Reporter: ______________________________ School:_____________________

Address:_____________________________________________Tel:______________________

Name DHHS/DA Intake Worker:__________________________ Date Reported: ____________


Requesting Confidentiality: YES NO


Student Information:

Name: _____________________________________ Age: _______ DOB: ____________

School: ___________________________________ Grade: _______ Gender: __________


Name of the primary caregiver;___________________________________________________

Address:____________________________________________Tel:________________________

__________________________________________________ Cell:________________________


Other Adults in the home:________________________________________________________


Other Children in the home:

Name of Child:__________________________________Age:___________Gender:_________

Name of Child:__________________________________Age:___________Gender:_________

Name of Child:__________________________________Age:___________Gender:_________

Name of Child:__________________________________Age:___________Gender:_________


Out of home parent;_________________________________________ TEL:_______________

Address:___________________________________________________ Cell:________________


Visitation/custody arrangement:__________________________________________


Child Care/Educational status:____________________________________________


Primary Language:____________________________________


Native American Heritage: YES NO

Presenting Issues/Concerns: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Domestic Violence Concerns:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Mental Health Concerns/Diagnosis:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Substance Abuse Concerns:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Service Providers:____________________________ Agency:________________________

Address:___________________________________________ Tel:______________________


Provider:____________________________________ Agency_________________________

Address:___________________________________________ Tel:_____________________


Provider:____________________________________ Agency_________________________

Address:___________________________________________ Tel:_____________________


Relative Resources:_______________________________ Relationship:________________

Address:__________________________________________ Tel:_______________________


Relative:________________________________________ Relationship:_________________

Address:__________________________________________ Tel:________________________

First Reading: 06/14/2017

Second Reading: 07/19/2017

First Reading: 09/28/2017

Second Reading: 10/18/2017

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