Portland Public Schools
Child Abuse Report Log
(To be kept on file in the school office)
Date: ________________ School: _________________________ Grade: _________
Student’s Name: ___________________________ Date of Birth: ______________
Does the student have a current IEP or 504 Plan? __Yes __No
Does the student have any medical problems or disabilities? __Yes __No
__Unknown If yes, please describe:
Student’s ethnicity: Parent/Guardian preferred language:
Interpreter needed? __Yes __No
Parent/Guardian: ______________________ Teacher: _________________________
Student’s Address: ______________________________________________________
Home Phone: _________________ Date of Alleged Abuse: ___________________
Alleged Incident:
________________________________________________________________________
Hotline Contact:
Employee reporting suspected abuse
to principal or principal’s designee: _________________________________________
Hotline Person Contacted: ________________________________________________
Principal/Staff Member Reporting to the Hotline: ______________________________
Agency responding (check one): Police Hotline
Name of Police Officer/Hotline Worker Responding: ___________________________
Badge Identification Number: _____________ Phone Number: _________________
Date and time of call: _____________________________________________________
Comments: _____________________________________________________________
If Student is Taken Into Custody At School:
Date: ____________________ Time: _______________________________
This report filled out by: _______________________________
DO NOT PLACE IN STUDENT’S CUMULATIVE FOLDER
