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  Suspected Child Abuse Incident Report (References: Policy P.090.SCO and Procedure PR.605.SCO)   School:        Name of Student:       DOB:        Parent(s)/Guardian(s): <br />       Grade/Class:        Parent(s)/Guardian(s):        Address:       Telephone:                   Reason(s) for suspecting child abuse:                                  <br />           Date of Referral:        Name of person reporting to CAS (OCDSB):        Name of CAS Worker:       Date:        Date of reporting to CAS:        Were parent(s)/guardian(s <br />) notified? Yes  No    Other persons consulted: Social Worker:        Psychologist:        School Resource Officer:        Other:              Date  Print <br />Name of Reporting Individual  Signature of Reporting Individual        Date  Print Name of Principal  Signature of Principal   The information on this form is collected <br />under the authority of the Child and Families Services Act and will be used ONLY to report suspected child abuse. This information is personal and should be managed in a highly confidential <br />manner. Access should be limited to those who have a need or established right. IN ACCORDANCE WITH OCDSB POLICIES AND PROCEDURES, THIS FORM MUST BE COMPLETED WITH ORIGINAL SIGNATURES. SEND <br />COMPLETED FORM TO COORDINATOR OF SOCIAL WORK, LEARNING SUPPORT SERVICES FOR DISTRIBUTION TO, AND REVIEW BY, THE SCHOOL SOCIAL WORKER. OCDSB 202 SOC (May 2009) Page 1 of 2