402.3E1 Abuse of Students by School District

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 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 _______________________

Your name, address and telephone number ______________________________________________________________

______________________________________________________________

______________________________________________________________

Relationship to student: ______________________________________________________________
______________________________________________________________

Complaint Signature Witness Signature

______________________________________________________________


Date Witness Name (Please print)

_______________________________________________________________
Witness Address