Coquille School District Suspected Abuse Reporting Form
All school district employees are mandatory reporters. If you suspect a child has been abused or neglected, you must make a report to Child Welfare or Law Enforcement immediately. Telling another employee or administrator does not relieve you of this legal obligation.
Complete the top section of this form when making a report to Child Welfare or Law Enforcement.
After making your report, complete the bottom section of the form and submit a printed copy of the form to your school counselor for filing purposes. You must also notify your administrator/supervisor after making your mandatory report. Do not email confidential information.
* Required
Email
*
Your email
Name of staff member filing report:
Your answer
Title:
Your answer
Student's Name
Your answer
Student ID#
Your answer
DOB
MM
/
DD
/
YYYY
School and Grade
Your answer
How Does the Student Get To/From School?
Your answer
Student's Address
Your answer
Student's Phone#
Your answer
PeopIe Living in the Student's Home
Your answer
Date Suspected Abuse Occurred
MM
/
DD
/
YYYY
Source of Information/Disclosure
Your answer
If 2nd Hand Information, Name/Contact of Person with 1st Hand
Your answer
Name of School Administrator
Your answer
Date Informed
MM
/
DD
/
YYYY
REPORT TO LEGAL AUTHORITY
Date report was filed:
MM
/
DD
/
YYYY
Time report was filed:
Time
:
AM
PM
Agency Notified (check all that apply):
Dept. of Human Services 1-855-503-7233
Coos County Sheriff (541) 396-7800
Coquille Police (541) 396-2114
Agency Contact Person (Name and Title):
Your answer
Outcome:
Your answer
Is the person of concern a district employee or volunteer?
Yes
No
Clear selection
If yes, immediately notify your school administrator or Human Resources/Prevention & Protection at 399-3061.
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