Section 300.APPENDIX A   Acknowledgement of Mandated Reporter Status

I,       (Employee name)      , understand that when I am employed as a       (Type of Employment)      , I will become a mandated reporter under the Abused and Neglected Child Reporting Act (Ill. Rev. Stat. 1985, ch. 23, pars. 2051 et seq.)  This means that I am required to report or cause a report to be made to the child abuse Hotline number (1-800-25A-BUSE) whenever I have reasonable cause to believe that a child known to me in my professional or official capacity may be abused or neglected.  I understand that there is no charge when calling the Hotline number and that the Hotline operates 24-hours per day, 7 days per week, 365 days per year.

I further understand that the privileged quality of communication between me and my patient or client is not grounds for failure to report suspected child abuse or neglect.  I know that if I willfully fail to report suspected child abuse or neglect I may be found guilty of a Class A misdemeanor.  This does not apply to physicians who will be referred to the Illinois State Medical Disciplinary Board for action.

I also understand that if I am subject to licensing under the Illinois Nursing Act, the Medical Practice Act, the Psychologist Registration Act, the Social Workers Registration Act, the Illinois Dental Practices Act, the School Code, or "AN ACT to regulate the practice of Podiatry in the State of Illinois," I may be subject to license suspension or revocation if I willfully fail to report suspected child abuse or neglect.

I affirm that I have read this statement and have knowledge and understanding of the reporting requirements which apply to me under the Abused and Neglected Child Reporting Act.

(Source:  Recodified from 89 Ill. Adm. Code 302, Appendix A, at 11 Ill. Reg. 3492)