Exhibit A (AR454)                                            **CONFIDENTIAL**

SCHOOL DISTRICT OF FORT ATKINSON

REPORT OF SUSPECTED CHILD ABUSE OR NEGLECT

CHILD’S NAME:                                           DATE OF BIRTH:                 AGE:

HOME ADDRESS:                                                              PHONE:                       

SCHOOL ATTENDED:                                                         GRADE:                       

PARENT/GUARDIAN:                                                          PHONE:                       

PARENT PLACE OF EMPLOYMENT:                                        PHONE:

DATE AND TIME OF ALLEGED INCIDENT (IF KNOWN):                                                           

OTHER SIBLINGS AND/OR SCHOOL AGE CHILDREN RESIDING IN RESIDENCE (IF KNOWN):

REPORTED BY:                               POSITION:                     PHONE:

ADMINISTRATOR/DESIGNEE:             POSITION:                     PHONE:

1.  Reasons for abuse/neglect suspicion (Include statements others made to you, noticeable physical injuries should be explained in detail).     (Use OTHER SIDE if more room is needed)

2.  Child’s explanation of injury or situation (Include: statements of child, statements allegedly made by the child to others and any surrounding circumstances and conditions in the home which the reporter is aware).     (Use OTHER SIDE if more room is needed)

3.   Action taken by school:  

IMPORTANT! NAME OF AGENCY PERSON you reported info to:                                          

Name of agency reported to:

(   ) Jefferson County Human Services      (date)_______________    (time)______________

(   ) Fort Atkinson Police Dept.                (date)_______________    (time)______________

(   ) Other Agency                                (date)_______________    (time)______________

4. Additional comments:                                                                                                                              

____________________________________________                                                                       

Signature of Reporter (OPTIONAL)                                              Date of Report

If any information documented on this form was not communicated to JCHS, the employee in the administrator or administrator’s designee presence will call JCHS back and review the additional information.

PLEASE SUBMIT THIS FORM TO THE BUILDING PRINCIPAL OR DESIGNEE AND SEND COPY TO DISTRICT ADMINISTRATOR