Suspected Child Abuse/Neglect Report Form
NEPN/NSBA Code: JLF-E
Any employee of the Yarmouth School Department who suspects that a child has been or is likely to be abused or neglected (the “notifying person”) must immediately notify the building administrator/designee using this form. The purpose of this form is to document your reporting and to facilitate confirmation to you that the building administrator/ designee 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 administrator/designee, 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 building administrator/designee 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: 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 building administrator/designee’s report to authorities)
Name of building administrator/designee:
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):
________________________________ _______________________
Building administrator/designee’s signature Date and Time
EMPLOYEE’S ACKNOWLEDGEMENT OF RECEIPT OF CONFIRMATION
(To be returned to building administrator/designee)
I have received confirmation that my report has been made to DHHS or the DA by the building administrator/designee.
______________________________________ __________________
Notifying Person/Original Reporter’s Signature Date and Time
________________________________________________________________________
(Employee’s Signature)
___________________________________
Date and Time
Approved: November 12, 2015
Revised: March 12, 2020
