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  • Writer's pictureBrett Saucier

JLF-E

Updated: Feb 5, 2021

NEPN/NSBA Code: JLF‐E 

SUSPECTED CHILD ABUSE/NEGLECT REPORT FORM 


Any employee of MSAD #60  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, including 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) 

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