Child Abuse And Neglect Report Form (4002b) Page 3
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3OFFICIAL DOCUMENT -DO NOT REPRODUCE
THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA
CHILD ABUSE AND NEGLECT FORM (CONFIDENTIAL)
(F.S. 39.202)
IDENTIFYING INFORMATION
SCHOOL _________________________________ PHONE _____________________________ AGE _____________________
CHILD ________________________________________________________________________ DOB_____________________
CHILD’S ADDRESS ____________________________________________________________
SEX _____________________
CITY __________________________________ STATE____________________ZIP_________ GRADE___________________
PARENT(S)/GUARDIAN(S)) _____________________________________________________
RACE ____________________
ADDRESS _____________________________________________________________________ FSI _____________________
CITY _____________________________________ STATE __________ ZIP______________
(Florida Student Identification Number)
HOME PHONE ____________________________ WORK PHONE ______________________
SIBLINGS NAMES ________________________________________________________________________________________
CASE INFORMATION
Circle the type(s) of suspected maltreatment:
Child –on – Child Sexual Abuse
Neglect
Domestic Violence
Threatened Harm
Need of Supervision and Care
Abandonment
Physical Abuse
Sexual Abuse
Psychological Maltreatment
Refer to the attached chart of some child abuse/neglect indicators. List observed indicators (physical and/or behavioral)
of possible maltreatments using the chart, or based on other information received from the student or others with
knowledge of the student’s situation:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
AdditionalComments________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Date and time reported to Hotline (1-800-96-ABUSE): ____________________________________________________
Hotline Counselor's Name ___________________ID#: ____________________________________________________
Was the report accepted for investigation? ____ Yes ______No. If No, enter the reason for refusal _______________
_________________________________________________________________________________________________
Is law enforcement involved? If so, name of Police Department:______________________________________________
Other pertinent information (e.g., relevant health information; knowledge of family situation; student services
involvement; prior abuse; drop in grades)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
REPORTER INFORMATION
Print Name (optional):______________________________
Date: ____________________________________
Title : ___________________________________________
Phone: ___________________________________
Send the completed form to Office Manager, School Social Work and Attendance, Kathleen C. Wright Administrative Center, 7th Floor
4002B
Approved June 1986
Revised 7/2005, 8/2006, 11/2007
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