TANNEHILL

                        SUSPECTED CHILD ABUSE REPORT FORM

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: ___________________________________________________________