Suspected Child Abuse Report Form printable pdf download

Suspected Child Abuse Report Form

JR-1

SUSPECTED CHILD ABUSE REPORT FORM

CHILD’S NAME:______________________________________DATE OF BIRTH:____________

ADDRESS:___________________________________________SCHOOL:___________________

PARENT(S)/LEGAL GUARDIAN:___________________________________________________

ADDRESS:______________________________________________________________________

I hereby acknowledge that I have a statutory duty to report any suspected abuse to DHS. I further

understand that merely filing this report does not absolve me of my statutory duty to report this

directly to DHS.

A copy of this suspected child abuse or neglect report may be filed with the Department of Human

Services, the supervising administrator and the Superintendent of Schools.

The supervising

administrator will also need to contact the DHS.

Describe the nature and extent of the suspected child abuse or neglect:________________________

_________________________________________________________________________________

Describe any evidence of previous suspected child abuse or neglect:__________________________

_________________________________________________________________________________

Names of persons present during the interview with the child:_______________________________

_________________________________________________________________________________

Name of investigating social worker with the Department of Human Services (if known):_________

_________________________________________________________________________________

Signature of Person Filing Report:_____________________________________________________

Signature of Supervising Administrator:________________________________________________

APPROVED: JUNE 30, 2011

DEER CREEK SCHOOL DISTRICT

Suspected Child Abuse Report Form