402.03E1 ABUSE OF STUDENTS BY SCHOOL DISTRICT EMPLOYEES REPORT

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.