JLF-E

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.

- If the alleged perpetrator is the parent or guardian or lives in the home, the report is filed with DHHS. The intake number is 1-800-452-1999.
- 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

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: ____________

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