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 need __________________________________________________________________________________________________

_______________________________________________________________________________________________________

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.