JLF-E (FORM) - SUSPECTED CHILD ABUSE, INCLUDING SEXUAL ABUSE, AND NEGLECT REPORT FORM
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):_____________________________________________________
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
- JLF – Reporting Child Abuse and Neglect
- JLFA – Child Sexual Abuse Prevention and Response
- JLF-R – Reporting Child Abuse, Including Sexual Abuse, and Neglect Administrative Procedure
- March 10, 2020