Child Abuse And Neglect Report Form (4002b) printable pdf download

Child Abuse And Neglect Report Form (4002B)

(DO NOT KEEP A COPY OF THE COMPLETED FORM AT THE SCHOOL)

All reports of suspected abuse, neglect, abandonment or a child in need of supervision and care must be made to the

Department of Children and Families (DFC) at the statewide toll-free hotline: (1-800-96-ABUSE). By law you may not

make an anonymous report as a professional reporter. You must give your name and contact information. Your name

will be held confidential by DCF and the investigating agency.

PURPOSE:

This form provides the school system with internal statistical information, and the ability to track and intervene when

there are multiple maltreatment incidents. Child Abuse Services also may assist schools/departments through consultation

regarding complex situations and the need for specific follow-up and supportive strategies. Child Abuses Services may

be reached directly at (754) 321-2492

DISTRIBUTION:

This form is a confidential document. Place the completed report form in a sealed envelope marked CONFIDENTIAL.

This envelope should then be placed in a pony envelope and sent immediately to the Office Manager, School Social Work

and Attendance Department (SSWAD) at the Kathleen C. Wright Administrative Center (KCW), 7

Floor. The form will

be transmitted by SSWAD to the Child Protective Investigation Section of the Broward Sheriff's Office (BSO).

COMPLETION OF FORM:

I. IDENTIFYING INFORMATION:

Enter all information requested in the spaces provided.

II. CASE INFORMATION:

Circle the type(s) of suspected abuse/neglect.

Refer to attached list of child abuse/neglect indicators and list observed indicators. Make any additional comments

you may have.

Check in the space provided to indicate whether the report was accepted for investigation. If the report was

not accepted, give the reason for denial.

If you have contacted law enforcement, please enter the name of the jurisdiction.

If you have any other information about the child or the situation which might be helpful in the investigative process,

please make your comments on the line designated for other pertinent information.

III. REPORTER INFORMATION:

Reporters are encouraged to identify themselves so that Child Abuse Services may contact them directly if needed.

This form will be given to the investigative agency. A copy will be retained by Child Abuse Services in a locked file

for five years, but will not be supplied or shared with anyone other than the reporter. The confidentiality of the

reporter will be maintained.

Child Abuse And Neglect Report Form (4002b)