Exhibit 1
District Policy 5540
ADAMS 12 Five Star Schools
CHILD ABUSE REPORT TO THE
ADAMS / BROOMFIELD COUNTY DEPARTMENT OF SOCIAL SERVICES
OR LAW ENFORCEMENT AGENCY
Division of Services for Families, Children and Youth
Name of Child
Birth Date
Sex
Address (include city and zip)
Parent’s/Guardian’s/Custodian’s Name
Address (include city and zip)
Telephone #
1. Name of Social Services worker contacted by phone
2. Nature and extent of the child’s injuries or evidence of neglect or molestation:
3. Child’s account of how the incident occurred:
4. Describe any evidence of previous known or suspected abuse or neglect to the child or to the child’s siblings:
5. Name(s), address(es) and relationship of the person(s) responsible for the suspected abuse or neglect, if known:
White: Social Services or Police Yellow: Staff Counsel Pink: School Copy
(Law Enforcement if third party abuse)
Form 95-1(Oct 2001) Page 1 of 2
Exhibit 1
District Policy 5540
ADAMS 12 Five Star Schools
CHILD ABUSE REPORT, CONTINUED
Name of Child
6. Other siblings, if known:
7. Other family members, if known:
8. Name, address, telephone number of school and the name and position of the person making the report:
9. Action taken by school:
A. Date and time of call to Department of Social Services:
B. Other:
10. Is the child receiving additional assistance at school outside of his/her regular classroom assignment?
Yes
No
If yes, please specify:
Any other information which may be helpful to Social Services’ investigation of this matter:
Date:
Signature
Position:
Please Print Name
School:
White: Social Services or Law Enforcement Yellow: Staff Counsel Pink: School Copy
(Law Enforcement if third party abuse)
Form 95-1(Oct 2001) Page 2 of 2
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