MAINE SCHOOL ADMINISTRATIVE DISTRICT NO. 31 SUSPECTED CHILD ABUSE/NEGLECT REPORT FORM
Any person employed through MSAD 31 who suspects that a child has been or is likely to be abused or neglected (the “notifying person”) must immediately notify the building principal and fill out this form. The purpose of this form is to document your reporting and to facilitate confirmation that a report has been made 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.
Piscataquis County: 564-2181 Penobscot County: 942-8552
This form is for school use only. It is not to be sent to DHHS.
Name of Notifying Person: __________________________ School:____________________ Address:__________________________________________ Tel:______________________ Email Address:______________________________________________________________ Date and time of notifying person’s report to principal: _____________________________ Name of school principal report made to: _________________________________________
Did notifying person request confidentiality: ______ Yes ______ No Did notifying person contact DHS independently: _____ Yes _____ No Name of DHHS/DA Intake Worker: ____________________________________________
Name of student who is subject of report: _______________________________________ Birthdate: __________________ Gender: ____________ Grade: _________________ Known history of abuse/neglect? ______________________________________________
Parent/Guardian Name(s): ___________________________________________________ Address: _________________________________________________________________ Home and work telephone numbers: ___________________________________________ Other Adults in the Home: ___________________________________________________
Name(s) of sibling(s) and/or other children in the home: Name:_________________________________ Age: ________ Gender: ____________ Name:_________________________________ Age: ________ Gender: ____________ Name:_________________________________ Age: ________ Gender: ____________ Name:_________________________________ Age: ________ Gender: ____________
Out of home parent: ______________________________ Telephone: _______________ Address: ________________________________________________________________ Visitation/ Custody Agreement: ______________________________________________
Primary Language: __________________ Native American Heritage: _____ Yes _____ No
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): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List any photographs taken or other materials collected related to the report: __________________________________________________________________________ __________________________________________________________________________
Actions taken by school personnel (list date, time and personnel involved): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CONFIRMATION OF REPORT FORM
(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)
First Reading: 03/20/2019
Second Reading: 05/02/2019 |