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Any employee of the Cape Elizabeth School Department who suspects that a child has been or is likely to be abused or neglected (the “notifying employee”) must immediately inform a school administrator, the Title IX Coordinator, or the Superintendent. The Superintendent or designee shall immediately make a report by telephone to the Department of Health and Human Services (DHHS) and, if appropriate, the District Attorney (DA), and complete this form. A copy should be provided to the notifying employee for signature and returned to the Superintendent. If the notifying employee has not received a copy of the completed form within 24 hours of informing a school administrator, the Title IX Coordinator, or the Superintendent, the employee shall make an immediate report to DHHS and, if appropriate, the DA, complete the form, and give it to the Superintendent.

This form is for school department use only. It is not to be sent to DHHS or the DA (unless requested by those agencies).


Name/title/telephone number/email address of notifying employee (person who first raises the suspicion):_______________________________________________________

Date and time of notifying employee’s report:___________________________________

Name/title of administrator notifying employee’s report first made to:________________

Name of student who is the subject of report:___________________________________ Birth Date:____________________ Gender:________________ Grade:____________ Known history of abuse/neglect?_____________________________________________

Parent/Guardian Name(s):__________________________________________________ Address:________________________________________________________________ Home telephone number(s):_________________________________________________ Work telephone number(s):__________________________________________________ Cell telephone number(s):___________________________________________________ Name(s) of sibling(s)/others in the home:______________________________________

Brief statement of indicators leading to the suspicion of abuse, including sexual abuse, or neglect:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Name/title/telephone number/email address of reporting employee (person who calls DHHS and/or the DA):_____________________________________________________

Agency contacted:_________________________________________________________

Name/title/telephone of agency contact:________________________________________

Date and time of telephone report:____________________________________________

Reporting Employee Signature Date

Did the notifying employee contact DHHS or the DA independently? ____Yes ____No

If No, the form should be given to the notifying employee for their signature and then returned to the Superintendent.

I have received written confirmation that my report has been made to DHHS or the DA by the Superintendent or designee.

Notifying Employee Signature					Date

Cross Reference:


  • March 10, 2020