Cut Bank School District

5232F

PERSONNEL

 

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: