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 number: _________________________________________________

Student’s attendance center: _________________________________________________

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:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Where there any witnesses to the incident or are there student 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 No._______________________________

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 (15) calendar days of filing this report unless the investigation is turned over to law enforcement.

 

Reviewed: 04/12/21