402.3E1 - Student Abuse Complaint 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 no.:            ___________________________________________________

Student's school:                       ___________________________________________________

Accused employee’s name and place of employment:__________________________________                                               

                                                ___________________________________________________

Allegation is of physical abuse or sexual abuse. (please circle)

*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                       Date             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.