Procedure #6196 B - Report of Suspected Child Abuse Form

Reporting of Suspected Child Abuse HRCSD Procedure #6196, revised 1-08 (re-numbered Procedure 9760) CHILD ABUSE/NEGLECT REPORTING FORM Directions: You may fill out this form on a computer and print it out for signatures. Child’s Name Date of Birth Child’s Grade School: Summary of report: Date Reported: Time Reported: Reported by HRCSD staff name: (list names of all reporters) Reported to DHS name: OR Reported to law enforcement name: Yes Is the suspected abuser is a District employee, substitute or volunteer? If YES, name of suspected abuser: If so, did you make the required report to the HRCSD Assistant Superintendent/Human Resources Director? No Signature Reporting Staff Date Signature School Administrator Date 1. Forward to Superintendent’s Office, when complete, in sealed envelope marked “Confidential.” A copy will be provided to the Human Resource Director/Assistant Superintendent if appropriate. 2. AND fax to DHS at (541)386-7066 OR Law Enforcement at (541)387-5585