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.
Email address *
Name of staff member filing report:
Title:
Student's Name
Student ID#
DOB
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School and Grade
How Does the Student Get To/From School?
Student's Address
Student's Phone#
PeopIe Living in the Student's Home
Date Suspected Abuse Occurred
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Source of Information/Disclosure
If 2nd Hand Information, Name/Contact of Person with 1st Hand
Name of School Administrator
Date Informed
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DD
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REPORT TO LEGAL AUTHORITY
Date report was filed:
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Time report was filed:
Time
:
Agency Notified (check all that apply):
Agency Contact Person (Name and Title):
Outcome:
Is the person of concern a district employee or volunteer?
Clear selection
If yes, immediately notify your school administrator or Human Resources/Prevention & Protection at 399-3061.
Submit
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This form was created inside of Coquille SD. Report Abuse