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CHILD'S NAME:                                                                                           DATE OF BIRTH: ______________________


ADDRESS:                                                                                                      SCHOOL:_____________________________


PARENT(S)/LEGAL GUARDIAN: ______________________________________________________________


ADDRESS: ________________________________________________________________________________


I hereby acknowledge that I have a statutory duty to report any suspected abuse to DHS.  I further understand that merely filing this report does not absolve me of my statutory duty to report this directly to DHS.


A copy of this suspected child abuse or neglect report may be filed with the Department of Human Services, the supervising administrator and the Superintendent of Schools.  The supervising administrator will also need to contact the DHS.


Describe the nature and extent of the suspected child abuse or neglect: ___________________________________






Describe any evidence of previous suspected child abuse or neglect: _____________________________________




Names of persons present during the interview with the child: __________________________________________




Name of investigating social worker with the Department of Human Services (if known): _______________________





Signature of Person Filing Report: _______________________________________________________________





Signature of Supervising Administrator: ___________________________________________________________