Jerome Joint School District No. 261

PERSONNEL 5260F

Report of Suspected Child Abuse, Abandonment or Neglect

Original to: Local Law Enforcement ____

Or Department of Health and Welfare ____

Building Principal ____

From: ______________________________________________ Title: ____________________________________________

School: _____________________________________________ Phone: __________________________________________

Persons contacted: ____Principal ____Teacher ____School ____Nurse ____Other:______________________________

Name of Minor: __________________________________________ Date of Birth: _________________________________

Address: ________________________________________________ Phone: ______________________________________

Date of Report: ______________________________ Attendance Pattern: _______________________________________

Father: ______________________ Address: ___________________________ Phone: ______________________________

Mother: Address: ______________________________________________ Phone: _________________________________

Guardian or Step-Parent: ________________ Address: ______________________________ Phone: _________________

Any suspicion of injury/neglect to other family members: ____________________________________________________

Nature and extent of the child's injuries, including any evidence of previous injuries, and any other information which may be helpful in showing abuse or neglect, including all acts which lead you to believe the child has been abused, abandoned and/or neglected: ___________________________________________________________________

Previous action taken, if any:_____________________________________________________________________________

_______________________________________________________________________________________________________

Follow-up by Local Law Enforcement / Department of Health and Welfare (copy to be completed and returned to

the Superintendent/Building Principal):

Date Received: _________________________________ Date of Investigation: ___________________________________

Policy History:

Adopted on: 03/25/2008

Revised on: 10/25/2022