402.3E1 - Abuse of Students by School District Employees

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.