File:  JLF-E - Written Report Cheraw School District #31 Child Abuse

Name of Child ______________________________ Birthdate _____________ Sex _______

Address: _____________________________________________________ Grade: _______

Parent (s) or Guardian:  ________________________________________________________

Parent´s Address (if different) _____________________________ Home Phone ____________

Parent´s Place of Employment ____________________________ Work Phone _____________

Family Composition ___________________________________________________________

1.  Check items that apply:

Dislocations/sprains______ Lack of Supervision ______ Emotional Neglect

______ Twisting/Shaking ______ Abandonment ______ Educational Neglect

______ Malnutrition ______ Burns, Scalds ______ Physical Neglect

______ Exposure to Elements ______ Medical Neglect ______ Sexual Abuse

Description: _________________________________________________________________

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2.  Briefly describe the reporter´s concern for the child. _________________________________

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3.  Describe the child´s account of how the incident occurred and name possible witnesses.________

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4.  Describe any previously known or suspected abuse or neglect to child or siblings. _____________

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5.  Provide name(s), address(es), and relationship to child of preson(s) responsible for suspected abuse or

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neglect (if known). ______________________________________________________________

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6.  Call to Social Services:

Date _______________ Time ____________  Person taking report _______________________

____________________________     ________________________     ___________________

Name of person reporting to DSS          Position                                         School

Print reporting forms in triplicate.  Send the original to your local social services agency and use the other copies for school district files.