Attachment A a erase rua DEPARTMENT OF HUMAN SERVICES cha Wllar Somes nate Unt 420 Waiakamilo Road, Suite 300A Honolulu, Hl 96817-4944 CONFIDENTIAL MANDATED REPORTER CHECKLIST FOR SUSPECTED CHILD ABUSE AND NEGLECT Oahu Reporting Li (808) 832-5300 Toll Free Neighbor Islands: 1-800-494-3991 ‘Oahu FAX: (808) 832-5292 Toll Free Neighbor Islands FAX: 1-800-399-1614 Tofile a report of Child Abuse and Neglect please: Review available records and fil out the checklist as completely as possible using _Y_for yes, .N for no, or as specified. Leave blank if unknown, unless otherwise indicated. 2. Immediately call the CWS Intake Reporting Line at (808) 832-6300 or toll free for neighbor islands at 1-800-494-3991 to report your findings. Be sure to obtain the name of the intake social worker to ‘document receipt and disposition of your referral. 3. FAX or Mail this document with comments to CWS immediately after verbally reporting to the intake worker. Doing so fulfils your statutory obligation under Chapter 350-1.1(c), Hawaii Revised Statutes, which requires a report in writing as well as the oral report. MANDATED REPORTER INFORMATION. Name/Agency/Tiie: ‘Adaress: Telephone: MANDATED REPORTER ORAL REPORT/CONTACT WITH CWS AND/OR POLICE, Name of CWS Intake Social Worker Date/Time of Report Name of Police Officer/Badge # Date/Time of ReporiPolice Report # alice, oF contract VOM or FSS provider for follow up? Yes __ No, PARENTICAREGIVER INFORMATION: (Circle where applicable) FATHER | GUARDIAN | OTHER | ALLEGED MOTHER | GUARDIAN | OTHER | ALLEGED MALTREATOR MALTREATOR Nam DOBIAge Name: ‘DOB/Age ‘Aaddress or Directions: ‘Address or Directions: Employment/Phone EmploymentPhone "Telephone: ‘Wiltary/Branch of Service | Telephone: Wiltary/Branch of Service DHS 1516 (oxp. 0403) Revised 0472015,(OTHER ALLEGED MALTREATERIS, Name: DOB/Age | Name: DOBIAGE ‘Address or Directions: ‘Address or Directions: Telephone: Telephone: Relationship to viet: Relationship to vic: (OTHER FAMILYHOUSEHOLD MEMBERS/SIGNIFICANT KIN Name DOB/Age Relationship to Victim: 7 2 3 a ‘CHILDIVICTIM INFORMATION Name DoB/ | Victim? | SchoolGrade/SPED | — Home Address/or Directions ‘Age | YIN 7 z 3 a EACTORS ‘A_TYPE OF HARM: Physical abuse “Threatened physical abuse ‘Sexual abuse “Threatened sexual abuse Physical neglect “Threatened physical neglect PaychologicaV/emotonal abuse. Threatened ical harm B._EVIDENCE OF HARM: [2 |_[Substaniaimutinle skin brusingiintemal Bleedng [| | | Extreme pain —] |_| injury causing substantial bleeding k_[ [Extreme mental distress ‘¢|_| Malnutrition |_| Gross degradation (extreme humiliation) ‘d-|_| Failure to thrive M_| | Death: fe |_| Burns. 1n_|_| Physical or medical evidence of sexual abuse ¥ |_| Poisoning ‘© } | Iniuty tothe psychological capacityimpairment in chile’ functoning ‘Any fracture P| _| Failure to provide adequate care or supervision |_| Subdural hematoma (per medical diagnosis) |_| _| Intentional Drugging LT [sof tissue sweling _[ [other . HISTORY, FREQUENCY, DURATION, INTENSITY OF HARM, if known by reporter: ‘Single incident, no history, no previous incidents Occurs repeatediy, several imes/year, escalating Infrequent incidents, no escalation short duration ‘Chronic and serious, ongoing pattern of harm DHS 1516 (exp. 04/03) Revised 0472015,D. BEHAVIORAL: (Has the child demonstrated any of the followit behaviors?) Danger to others: Assaults/aggression ‘Status Offenses or Law Violation a b | | Dangerto selfself destructive/suicidal Education/Academic Difficulties ¢ |_| Mental Health Issues, Withdrawal or depression Fear of caretaker/returning home/being harmed || inappropriate sexual knowledge/seductive again ‘Other: Spec E. SERVICES/TREATMENT HISTORY: Has the family participated or been offeredireferred to any service or treatment prior to the report of harm such as: (Yes, No, Unknown, or Declined, Identified as a need) If known, identify service provider and contact ‘Support system available to the child and family, willing and able to assi information. a Parenting classes a Medicattieatth Services b Family violence services (domesticfamily | h_| | Public Health Nursing abuse) © ‘Educational programs i ‘Substance abuse counseiingfreatment Inpatient___ Outpatient a Thdlvidual counseling or therapy T ‘Anger management e Intensive home based (outreach, home visi)_| k_| | CWS involvement (Hawail or other) f ‘Mental Health (Psychiatric Services, i ‘other, S If known, identify person(s) and contact information. a Parents, F Friends b Maternal grandparents c ‘Church members: ¢ Paternal grandparents h ‘Community groups d Siblings. i Service providers. e Other relatives fl Other: specify below G_NARRATIVE INFORMATION: Please provide a brief narrative descr ‘of the incident(s) and what action you believe needs to be taken. If known, include dates and location. (Use additional sheets as needed) THANK YOU FOR YOUR ASSISTANCE. HS 1516 (exp. 04/0) Revised 0472015,Attachment B Mandatory Child Abuse and Neglect Reporting School Checklist § 350-1.1 Hawaii Revised Statutes (HRS) mandates all employees or officers of the Department of Education to report suspected cases of child abuse and neglect to proper authorities. The following checklist outlines the procedures for filing a report when. employees or officers of the Department of Education suspect child abuse or neglect. > Employee or officer of the DOE who suspects that child abuse or neglect has ‘occurred or that there exists a substantial risk that child abuse or neglect may occur in the reasonable foreseeable future by a family member of the child or in the family home of the child, shall report the suspected case to the proper authorities. ial o Consider the potential need for an interpreter when engaging with a non- English speaking student regarding alleged abuse or neglect. Call Child Welfare Services (CWS) and immediately notify the principal or the designee of the report made. If the suspected abuse is sexual in nature or it is determined that the student ‘may be in imminent harm at home, the school staff member shall contact the county police immediately after calling CWS. At no time shall the principal/designee or staff member interview the student suspected of sexual abuse. Ifa call is made to the county police by the staff member, the person shall immediately notify the principal/designee of the call. Employee or officer of the DOE shall complete form DHS 1516 - Mandated Reporter Checklist for Suspected Child Abuse and Neglect 1 Reporter completes DHS 1516 — Mandated Reporter Checklist FAX checklist to CWS immediately after verbally reporting to CWS CO Send the original checklist to: Maureen Ikeda Comprehensive Student Support Services Section 475 22"4 Avenue, Room 204 Honolulu, HI 96816 > Employee or officer of the DOE who suspects that child abuse or neglect has occurred or that there exists a substantial risk that child abuse or neglect may occur in the reasonably foreseeable future by someone other than a family member of the child or outside of the family home of the child, shall report the suspected case to the proper authorities. a Q | a Consider the potential need for an interpreter when engaging with a non-English speaking student regarding alleged abuse or neglect Immediately call parent(s) Immediately call the county police Ifa call is made to the parent(s) or the county police by the staff member, the person shall immediately notify the principal/designee of the call(s) OCISS/CSSSS, 07/2016