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). 

 Notification 

 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:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

 Report 

 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: 

 

 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 

 

 Adopted: 

 

 March 10, 2020