Acknowledgment Form For Children'S Centers printable pdf download

ACKNOWLEDGMENT FORM

for Children’s Centers

Child Abuse & Neglect Reporting Requirements

All child care personnel are mandated by law to report their suspicions of child abuse, neglect, or

abandonment to the Florida Abuse Hotline in accordance with Chapter 39.201 of the Florida

Statutes (F.S.).

Child care personnel must be alert to the physical and behavioral indicators of child abuse and neglect.



“Child Abuse or Neglect” is defined in s. 39.201, F.S., as “harm or threatened harm” to a child’s health

(mental or physical) or welfare by the acts or omissions by a parent, adult household member, other

person responsible for the child’s welfare, or for purposes of reporting requirements by any other person.

Categories include:



- Physical Abuse or Neglect (i.e. unexplained bruises, hunger, lack of supervision…)

- Emotional Abuse or Neglect (i.e. impairment in the ability to function, depression…)

- Sexual Abuse (i.e. withdrawal, excessive crying, physical symptoms…)

Reports must be made immediately to the centralized Florida Abuse Hotline Information System by



-Telephone at 1-800-96-ABUSE (962-2873), or

-Fax at 1 800-914-0004, or

-Online at

Failure to perform duties of a mandatory reporter pursuant to s 39.201, F.S. constitutes a violation of the



standards in ss. 402.301-319, F.S. and is a felony of the third degree. Remember, it is each child care

Personnel’s responsibility to report suspected abuse and/or neglect.

All reports are confidential. However, persons who are mandated reporters (such as child care



personnel) are required to give their name when making a report.

It is important to give as much identifying information and factual information as well as physical and



behavioral indicators of abuse and neglect when making a report.

Any person, when acting in good faith, is immune from liability in accordance with s. 39.203(1)(a), F.S.

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For more information about child abuse and neglect, visit the Department of Children Family Services’



Identifying and

website at

and select “Training Requirements”. A 4-hour

Reporting Child Abuse and Neglect

course is offered for child care providers. This course is an overview

of the various types of abuse and neglect, indicators that may be observed, the legal responsibility of

mandatory reporters, and the proper procedure for reporting abuse and neglect, as required by ss. 402-

305 (2) and 402.313(1), F.S. The course is offered both online and instructor-based throughout Florida.

This statement is to verify that on _________, 20___, I, _____________________________________

Date

Print Name of Director, Owner, Employee, or Substitute

read and understood the information and my mandated reporting requirements.

________________________________________

Signature of Employee or Substitute

Signature of Director or Owner

Statement Concerning Previous Employment

This statement must be signed by all children’s center staff members on or before hire date.

It does not need to be signed again unless there is a 90 day break in service.

Have you ever worked in a facility that has had a license denied, revoked or suspended in any state OR been the

subject of a disciplinary action or been fined while employed in a children’s center?

Yes

I attest under penalty of perjury that the above answer is true

__________________________

Signature of Employee or Substitute

Date

C-0071 Required (Rev 11/12)

Acknowledgment Form For Children'S Centers

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