406.2E1 Complaint Form for Injury to or Abuse of Student By 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 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 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.

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