La Plata, Maryland 20646
/report of suspected child abuse/child neglect
INSTRUCTIONS: Respond to each item even if reply is “unknown” or “none”. For suspected child abuse/neglect, an oral report must be made to the Protective Services Unit of the Charles County Department of Social Services, telephone 301-392-6739 or the Charles County Sheriff’s Office, telephone 301-932-2222. This report must be filed within 48 hours after making an oral report. Type or print firmly on a hard surface. (See reverse side for definitions and additional instructions.)
Person Making ReportName: Position:
School Name: School Phone:
Check type of referral:
Physical Abuse Sexual Abuse NeglectName of Child: Sex:
Address (where child may be seen):
DOB: Grade: Race: /
Name of Siblings DOB
1.2.
3.
4.
5.
Name of Person(s) Responsible for Child’s Care (Parent/Guardian)
Father: Phone:Mother: Phone:
Guardian: Phone:
Relationship of Guardian, if any:
Address: Zip Code:
Name of Suspected Abuser: Phone:
Address:
Relationship (of Suspected Abuser) to Child:
State the nature and extent of the current injury to the child or the circumstances leading to the suspicion that the child is a victim of abuse/neglect.
Give information concerning previous injury or conditions of neglect to this child or other children in this family situation, including previous action taken, if any.
State any other information available to you, which would be of aid in establishing the cause of the injuries and/or neglect.
Date and Hour of Oral Report Name of Person to Whom Oral Report Was MadeSignature of Person Making Report Date Mailed
Copies to: Department of Social Services; Charles County Sheriff’s Office; Supervising Pupil Personnel Worker-Office of Student Services; State’s Attorney for Charles County; School Copy
PS:KG/jk
April 2011
h:/forms,reportofchildabuse.doc
DEFINITIONS OF CHILD ABUSE AND CHILD NEGLECT
I. CHILD ABUSE means: physical injury, not necessarily visible, of a child under circumstances that indicate that the child’s health or welfare is significantly harmed or at risk of being significantly harmed, by a parent (including any stepparent or foster parent) or other person who has permanent or temporary care, guardianship, or custody or responsibility for supervision of a child, or by any household or family member.
II. SEXUAL ABUSE means: an act or acts involving sexual molestation or exploitation, whether physical injuries are sustained or not, by a parent (including any stepparent or foster parent) or other person who has permanent or temporary care, guardianship, custody or responsibility for supervision of a child, or by any household or family member.
III. CHILD NEGLECT means: the failure to give proper care or attention to a child, including the leaving of a child unattended, under circumstances that indicate that the child’s health or welfare is significantly harmed or placed at risk of significant harm, by a parent, guardian or custodian.
ADDITIONAL INSTRUCTIONS FOR REPORTING CHILD ABUSE
1. An oral report of suspected child abuse must be made immediately during school hours. A written report must be submitted. It is not necessary to observe outward signs of injury to the child. Neither is it necessary for the reporter to establish proof that abuse has occurred. Protection of the child is paramount. If abuse is suspected, a report must be submitted.
2. Every health practitioner, educator, social worker or law-enforcement officer, who contacts, examines, attends or treats a child and who believes or has reason to believe that the child has been abused, is required to make a report to either Social Services at 301-392-6739 or Police at 301-932-2222 (24 hours).
3. Any person including a health practitioner, educator, social worker or law-enforcement officer participating in the making of a good faith report or participating in an investigation or in a judicial proceeding resulting there from shall, in so doing, be immune from any civil liability or criminal penalty that might otherwise be incurred or imposed as a result.
ADDITIONAL INSTRUCTIONS FOR REPORTING CHILD NEGLECT
1. The 1978 Maryland State Law requires all health practitioners, educators, social workers, and law-enforcement agencies or officers to report suspected child neglect.
2. An oral report of suspected child neglect must be made to either Social Services at 301-392-6739 or Police at 301-932-2222 (24 hours) as soon as is reasonably possible upon suspicion of child neglect. A written report must be submitted within 48 hours.
3. Any person other than a person suspected of child neglect who, in good faith, makes or participates in making a report of neglect or who participated in an investigation or in a resulting judicial proceeding, is immune from any civil liability or criminal penalty that might otherwise be incurred or imposed as a result.
COPY TO: COPY TO:
Charles County Department of Social Services Charles County Public Schools
Child Protective Services Office of Student Services
200 Kent Avenue ATTN: Supervising Pupil Personnel Worker
La Plata, Maryland 20646 P. O. Box 2770
La Plata, Maryland 20646
COPY TO: COPY TO:
Charles County Sheriff’s Office School
Child Abuse Unit
6915 Crain Highway
La Plata, Maryland 20646
COPY TO:
State’s Attorney Office for Charles County
P. O. Box 3065
La Plata, Maryland 20646