Students AP 325 - Form 325-1: Report Regarding Suspected Abuse/Neglect

1. Alleged

 Psychological Neglect:Physical Abuse:Criminal Harrasment Abuse: Emotional Abuse: Sexual Abuse: Other (i.e. Prostitution or Substance Abuse):

2. Specific Concerns and Observations:

3. Information

Name of Student:Date of Birth:Student's Address:Telephone:Name of Mother (or Guardian):Address:Telephone:Name of Father (or Guardian):Telephone:Address:

4. Reporting
Child Youth and Family Enhancement Act Section 4(1) states "any person who has reasonable and probable grounds to believe that a child is in need of intervention shall forthwith report the matter to a Director"
Basis

5.  Reported to Northeast Child and Family Services Authority:Name of Case Worker/Investigator:Telephone Number of Worker/Investigator:6. Name Of Staff/Person Making Report:Date:Principal's Signature:School:

7.   Attach notes summarizing subsequent contacts and disposition if known.