NOTE:

For official copies of board policies and procedures please contact the superintendent's office at (253) 583-5190 or email supt@cloverpark.k2.wa.us

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CONFIDENTIAL
CLOVER PARK SCHOOL DISTRICT
CHILD ABUSE AND NEGLECT REPORT
RCW 26.44.040
Form 3421-F1

Student Name: Birthdate: Gender

Student Address Phone

Name of Parent/Custodian/Guardian

Please check type of abuse being reported:




State the “reasonable cause” that led you to believe that abuse occurred: (What happened?, When did it happen?, Where did it happen?, Who is alleged to have done the abuse?)

Provide any information regarding the identity of the alleged perpetrator:

State any evidence of previous injuries:

Oral report made to: (Agency Personnel)

Child protective Services
Daytime Intake: 253-983-6100 Fax: (253-593-5066
After 4:30 pm, weekends and holidays: 1-800-422-7517
Report Date
Report Time
MAIL: CPS Intake, 1949 S. State ST, Tacoma, WA 98405
Lakewood Police Dept. (9-1-1 or 798-4721) Fax: (253) 830-5069
MAIL: LPD, 9401 Lakewood DR SW, Lakewood, WA 98499

 


Reporting Staff Member
Signature

Printed Name

Title

Date
Building Administrator
Signature

Title

Date

School Phone

Address


Send signed hard copies to: CPS or LPD, Student Services, and Risk Management
Do not email this form.