Report Regarding Suspected Abuse/Neglect

1. Alleged

Psychological Neglect:

Physical Abuse:

Criminal Harrasment Abuse:

Emotional Abuse:

Sexual Abuse:

Other (i.e. Prostitution or Substance Abuse):

2. Specific Concerns and Observations:

3. Information

Name of Student:

Date of Birth:

Student's Address:

Telephone:

Name of Mother (or Guardian):

Address:

Telephone:

Name of Father (or Guardian):

Telephone:

Address:

4. Reporting
Child Youth and Family Enhancement Act Section 4(1) states "any person who has reasonable and probable grounds to believe that a child is in need of intervention shall forthwith report the matter to a Director"
Basis

5. Reported to Northeast Child and Family Services Authority:

Name of Case Worker/Investigator:

Telephone Number of Worker/Investigator:

6. Name Of Staff/Person Making Report:

Date:

Principal's Signature:

School:

7. Attach notes summarizing subsequent contacts and disposition if known.
This form and documentation is to be kept in a separate confidential file by the School Administrator