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