PrintUCLA Mandated Reporter Identification Form
UCLA MANDATED REPORTER IDENTIFICATION FORM
Departments must submit this completed form to the departmental human resources or academic personnel representative on behalf of any UCLA Employee or Official who is a “UCLA Mandated Reporter” (see UCLA Policy 136) and retain a copy in the Employee’s personnel file. Departments of UCLA Health are exempt from completing this form.
An individual identified as a UCLA Mandated Reporter will be given a hard copy of or web link to UCLA Policy 136 and must sign and return the UCLA Mandated Reporter Acknowledgement Statement (See UCLA Policy 136, Attachment B) to the department, wh9ich will forward the signed acknowledgement to the departmental human resources or academic personnel representative for retention in the Employee’s personnel file.
UCLA Mandated Reporter’s Name: ____________________________ UCLA ID#: _________________
UCLA Employee is any individual who receives compensation through the University’s payroll system or holds a UCLA academic appointment.
UCLA Official (referred to as an “administrator” in CANRA) is any individual, other than an Employee, an independent contractor, or a volunteer who supervises University activities, functions or programs).
Job Title: ________________________________ Supervising Department: _______________________
The individual is a UCLA Mandated Reporter because the individual (check all that apply):
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is an Employee or Official or other position at UCLA, who by virtue of their licensure, has a duty to report under CANRA |
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who, within the scope of their employment or other position at UCLA, has duties that bring them into direct and regular contact with a Child who is under 18 (this does not include faculty or instructors whose only contact with a child is teaching a class) |
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is a researcher whose projects include a Child in activities that are on University premises, or at an activity or program conducted or overseen by the University |
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is a law enforcement or public safety professional, including University police officers and police department Employees and fire marshals |
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is a licensed healthcare professional or resident/trainee/intern who is in training to become a licensed healthcare professional |
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is a teacher, aide, counselor, or administrator at K-12 schools, including the UCLA Lab School and Geffen Academy |
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is a licensee, contractor, caretaker, or administrator at a preschool, community care, or child day care center, including but not limited to the Krieger Center, Fernald Center, University Village Center, Infant Development Program, UCLA Westwood Child Care Center, and University Parents Nursery School |
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is an administrator or counselor at a day camp, summer camp, etc. where children attend, reside, or otherwise participate, including the Lake Arrowhead Conference Center & Bruin Woods Family Resort |
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is a coach, trainer, managerial or professional staff, or assistant in University-sponsored athletic or recreational activities in which a child participates, including the Department of Intercollegiate Athletics or UCLA Recreation & Campus Life |
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is an Employee or Official engaged in theater and film production in which a Child participates |
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directly supervises one or more UCLA Mandated Reporters |
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is an Employee or Official, including faculty, who accompanies students under 18 for educational or travel programs, including study abroad |
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is an Employee who accepts complaints of discrimination, harassment, retaliation, etc. based on categories protected under the California Fair Employment and Housing Act (FEHA). This may include Employees from human resources, academic personnel, Title IX, AA/EEO, Employee and Labor Relations, or any other offices who are designated to receive complaints of harassment and discrimination based on categories protected under FEHA. This also includes Employees whose duties require direct contact with, or supervision of, a Child in the workplace of an office subject to FEHA
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other reason (explain): ____________________________________________________________ |
Department Head or Designee completing this form:
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Name of Department Head or Designee |
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Job Title |
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Signature of Department Head or Designee |
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Date |
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Department |
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