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I,	, understand that when I am employed at
(Employee Name-First, Middle, Last)
Southern Illinois University Edwardsville	, I will become a mandated reporter under the
Abused and Neglected Child Reporting Act [325 ILCS 5/4]. 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 but not limited to the following acts: the Illinois

Nursing Act of 1987, the Medical Practice Act of 1987, the Illinois Dental Practice Act, the School Code, the

Acupuncture Practice Act, the Illinois Optometric Practice Act of 1987, the Illinois Physical Therapy Act, the

Physician Assistants Practice Act of 1987, the Podiatric Medical Practice Act of 1987, the Clinical Psychologist

Licensing Act, the Clinical Social Work and Social Work Practice Act, the Illinois Athletic Trainers Practice

Act, the Dietetic and Nutrition Services Practice Act, the Marriage and Family Therapy Act, the Naprapathic

Practice Act, the Respiratory Care Practice Act, the Professional Counselor and Clinical Professional Counselor

Licensing Act, the Illinois Speech-Language Pathology and Audiology Practice Act, 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.
Signature of Applicant/Employee
Date
CANTS 22
Rev. 2/2012

Joyree Chura

2012-08-28

Southern Illiniois University Edwardsville