ACKNOWLEDGEMENT OF MANDATED REPORTER STATUS
I, , understand that when I am employed as a
(Employee Name)
Higher Education Employee
(Type of Employment)
, I will become a mandated reporter under the
Abused and Neglected Child Reporting Act [325 ILCS 5/4]. This means that I am required to report or cause a
report to be made to the child abuse Hotline number at 1-800-25-ABUSE (1-800-252-2873) whenever I have
reasonable cause to believe that a child known to me in my professional or official capacity may be abused or
neglected. I understand that there is no charge when calling the Hotline number and that the Hotline operates
24-hours per day, 7 days per week, 365 days per year.
I further understand that the privileged quality of communication between me and my patient or client is not
grounds for failure to report suspected child abuse or neglect, I know that if I willfully fail to report suspected
child abuse or neglect, I may be found guilty of a Class A misdemeanor. This does not apply to physicians who
will be referred to the Illinois State Medical Disciplinary Board for action.
I also understand that if I am subject to licensing under but not limited to the following acts: the Illinois
Nursing Act of 1987, the Medical Practice Act of 1987, the Illinois Dental Practice Act, the School Code, the
Acupuncture Practice Act, the Illinois Optometric Practice Act of 1987, the Illinois Physical Therapy Act, the
Physician Assistants Practice Act of 1987, the Podiatric Medical Practice Act of 1987, the Clinical Psychologist
Licensing Act, the Clinical Social Work and Social Work Practice Act, the Illinois Athletic Trainers Practice
Act, the Dietetic and Nutrition Services Practice Act, the Marriage and Family Therapy Act, the Naprapathic
Practice Act, the Respiratory Care Practice Act, the Professional Counselor and Clinical Professional Counselor
Licensing Act, the Illinois Speech-Language Pathology and Audiology Practice Act, I may be subject to license
suspension or revocation if I willfully fail to report suspected child abuse or neglect.
I affirm that I have read this statement and have knowledge and understanding of the reporting requirements,
which apply to me under the Abused and Neglected Child Reporting Act.
WIU ID Number (if known/otherwise to be completed internally) Signature of Applicant/Employee
Date
Civil Service
Faculty/A&P
Graduate Assistant
Student Worker
All Student Workers forms should be returned to Student Emploment office, Sherman Hall 121
CANTS 22
Rev. 8/2013
Office of the Director
406 E. Monroe Street • Springfield, Illinois 62701
www.DCFS.illinois.gov
