Policy Manual

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Policy JLF-E

Any employee of South Portland School Department who suspects that a child has been or is likely to be abused or neglected must immediately notify the building principal/his or her designee using this form. The purpose of this form is to document your reporting and to facilitate confirmation to you that the building principal or other designated school official  has made your report to the Department of Health and Human Services (DHHS) or, as appropriate, to the District Attorney.

If you have not received written confirmation within 24 hours of submitting this form to the building principal, you must make your own report to DHHS or, if appropriate, to the DA.

1. Name/title/telephone number and email address of notifying person (person who originally has the information and is required to report it):  

______________________________________________________________________________________

______________________________________________________________________________________

2. Date and time of notifying person’s report: ___________________________________________________

3. Name/title of school principal/designated agent first report made to:   ______________________________________________________________________________________

4. Did notifying person contact DHS independently: _____ Yes _____ No 

5. Name of student who is subject of report: ____________________________________________________   

Birthdate: _______________________ Sex: ___________________ Grade: ________________________   

Known history of abuse/neglect? ___________________________________________________________   

Parent/Guardian Name(s): ________________________________________________________________   

Address: ______________________________________________________________________________   

Home and work telephone numbers: ________________________________________________________   

Name(s) of sibling(s): ____________________________________________________________________ 

6. Has the family been prepared for the referral? Yes No

7. Has the notifying person given permission for his/her name to be used by the Department of Human Services? Yes No

8. Statements or indicators leading to the suspicion of abuse/neglect (include all known information, including date, time and location, name of alleged abuser, and relationship to student):

______________________________________________________________________________________  

______________________________________________________________________________________   ______________________________________________________________________________________   ______________________________________________________________________________________   ______________________________________________________________________________________ 

9. List any photographs taken or other materials collected related to the report: _________________________  ______________________________________________________________________________________   ______________________________________________________________________________________

10. Actions taken by school personnel (list date, time and personnel involved):

______________________________________________________________________________________   ______________________________________________________________________________________   ______________________________________________________________________________________   ______________________________________________________________________________________   ______________________________________________________________________________________

Confirmation Of Report  

(Used for confirming principal or designated agent’s report to authorities) 

Name of principal or designated agent: ______________________________________________________   

Agency contacted by telephone:  ___________________________________________________________   

Name and title of agency contact:  __________________________________________________________   

Date and time of telephone report: __________________________________________________________   

Copy of report form sent (include date and addressee): __________________________________________

______________________________________________________________________________________

__________________________________________ __________________   

Principal/Designated Agent Signature Date and Time

Employee’s Acknowledgement Of Receipt Of Confirmation

(To be returned to principal or designated agent) 

I have received confirmation that my report has been made to DHHS or the DA by the Principal or other Designated Agent.  

_____________________________________________ __________________  

Notifying Person/Original Reporter’s Signature Date and Time  

(Employee’s Signature)  

Adopted: March 13, 2017

*Please excuse any formatting errors.