Elkhorn Public Schools Suspected Child Abuse And/or Neglect Report Form printable pdf download

ELKHORN PUBLIC SCHOOLS

SUSPECTED CHILD ABUSE AND/OR NEGLECT REPORT FORM

(Type or print all information)

CHILD __________________________________________________ DATE ____________________

SCHOOL __________________________ AGE ______ BIRTHDATE ____________ SEX: M

PARENT(S)/GUARDIAN(S) HAVING CUSTODY ____________________ DATE OF INCIDENT __________

ADDRESS _______________________________________________ TELEPHONE ________________________

TYPE OF SUSPECTED ABUSE OR NEGLECT: (Check all that apply)

_____ Burns

_____ Fracture

_____Sexual Abuse

_____ Beating

_____ Neglect

_____ Abandonment

_____ Malnutrition

_____ Other (Specify) ______________________________________________________________

LOCATION OF INJURIES (If applicable): ___________________________________________________________________

REASON(S) FOR SUSPECTING ABUSE/NEGLECT: _________________________________________________________

_______________________________________________________________________________________________________

NAME AND ADDRESS OF SUSPECTED ABUSER: __________________________________________________________

_______________________________________________________________________________________________________

CHILD’S ACCOUNT OF INJURY OR SITUATION: __________________________________________________________

_______________________________________________________________________________________________________

OTHER PERTINENT INFORMATION (e.g. Relevant health information, knowledge of family situation, etc.) _____________

_______________________________________________________________________________________________________

Was Child Protective Services Contacted? ____ Yes ___ NO

If yes, who was notified?___________________________________________________________________________________

(Name)

(Position/Jurisdiction)

(Date contacted)

Was law enforcement contacted? ____ Yes ____ No

If yes, who was notified?___________________________________________________________________________________

(Name)

(Position/Jurisdiction)

(Date contacted)

Was anyone else notified? ____ Yes ____ No

If yes, who was notified?___________________________________________________________________________________

(Name)

(Position/Jurisdiction)

(Date contacted)

_______________________________________________________________________________________________________

(Signature of person competing report)

(Title/Position)

(Date)

COPIES: Original -- School (Confidential file—DO NOT place in student file)

Copy 1 – Superintendent of Schools

Elkhorn Public Schools Suspected Child Abuse And/or Neglect Report Form

Related Articles

Related forms

Related Categories