406.2E1 Complaint Form for Injury to or Abuse of Student by School District Employees Regulations

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