402.03E1 - Abuse of Students by School District Employees Report Form

ABUSE OF STUDENTS BY SCHOOL DISTRICT EMPLOYEES
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.:  ___________________________

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

Allegation is of:  _________________  Physical Abuse     _________________  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 twelfth 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 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 of 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.