Tomorrow River School District

Confidential

TOMORROW RIVER SCHOOL DISTRICT Child Abuse/Neglect Reporting Form

School: Amherst Elementary Amherst Middle Amherst High

Student Name______

DOB ___/___/______Male____ Female____

Student Address ______

Name of student’s custodial parent:______

Phone number of custodial parent: ______

Reason for Report: Include reason for concern, date of incident, and any observations or pertinent information.

______

______If necessary, continue report on the back of this form.

Report made by: ______

Position: ______

Date: ____/____/______Time: ______a.m p.m.

Portage County Health and Human Services phone number: 715-345-5350  Select option 3- “Calling to report child abuse or neglect, parent-child conflict, or any other child welfare concern.”  You will be asked to provide the student information from above.

*Optional, but highly recommended: give original or copy to appropriate Administrator and/or School Counselor Confidential

**Remember this is a confidential form. It should be stored or destroyed appropriately.