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IHEB Report Regarding Suspected Abuse/Neglect - Exhibit 1

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)
Address
Telephone

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.

This form and documentation is to be kept in a separate confidential file by the School Administrator

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