Cut Bank School District




Cut Bank School District

Report of Suspected Child Abuse or Neglect


Original to: Department of Family Services

Copy to: Building Principal


From: Title:


School: Phone:


Persons contacted: Principal Teacher School Nurse Other


Name of Minor: Date of Birth:


Address: Phone:


Date of Report: Attendance Pattern:


Father: Address: Phone:


Mother: Address: Phone:


Guardian or

Step-Parent: Address: Phone:


Any suspicion of injury/neglect to other family members:


Nature and extent of the child's injuries, including any evidence of previous injuries, and any other information which may be helpful in showing abuse or neglect, including all acts which lead you to believe the child has been abused or neglected:


Previous action taken, if any:


Follow-up by Department of Family Services (DFS to complete and return copy to the Building Principal):


Date Received: Date of Investigation: