402.3E1 - Abuse of Students by School District Employees Report Form

Complaint of Injury to or Abuse of a Student by a School District Employee

 

Please complete the following as fully as possible.  If you need assistance, contact the Level I investigator in your school.

Student's name and address:

_____________________________________________________________

Student's telephone no.: __________________________________________

Student's school: _______________________________________________

Name and place of employment of employee accused of abusing student:

_____________________________________________________________

_____________________________________________________________

 

Allegation is of                                   physical                                     sexual abuse*

Please describe what happened.  Include the date, time and where the incident took place, if known.  If physical abuse is alleged, also state the nature of the student's injury: _____________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

 

Were there any witnesses to the incident or are there students or persons who may have information about this incident?            yes             no

            If yes, please list by name, if known, or classification (for example: "third grade class," "fourth period geometry class"): __________________________________________

________________________________________________

 

*Parents of children who are in pre-kindergarten through sixth grade and whose children are the alleged victims of or witnesses to sexual abuse have the right to see and hear any interviews of their children in this investigation.  Please indicate "yes" if the parent/guardian wishes to exercise this right:

                         Yes                   No      Telephone Number                                                                     

 

Has any professional person examined or treated the student as a result of the incident?

                   yes                 no             unknown

If yes, please provide the name and address of the professional(s) and the date(s) of examination or treatment, if known:________________________________________

________________________________________________

________________________________________________

 

Has anyone contacted law enforcement about this incident?            yes             no

Please provide any additional information you have which would be helpful to the investigator.  Attach additional pages if needed.

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

 

Your name, address and telephone number:

_____________________________________________________________

_____________________________________________________________

 

Relationship to student:__________________________________________

 

                                                                                                                                        
Complainant Signature                                      Witness Signature

 

                                                                                                                                        
Date                                                                   Witness Name (please print)

 

                                                                                                                
                                                               Witness Address

 

Be advised that you have the right to contact the police or sheriff's office, the county attorney, a private attorney, or the State Board of Educational Examiners (if the accused is a licensed employee) for investigation of this incident.  The filing of this report does not deny you that opportunity.

You will receive a copy of this report (if you are the named student's parent or guardian) and a copy of the Investigator's Report within fifteen calendar days of filing this report unless the investigation is turned over to law enforcement.

 

 

Approved_09/11/95   
Reviewed 10/18/21              
Revised   11/11/13