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105.1-E Injury/Abuse of Student by School Employee Report Form




Click here to download Policy 105.1-E - Injury/Abuse of Student by School Employee Report Form

Please complete the following as fully as possible. If you need assistance, contact the district's Level I investigators as listed on page 2. 

Student's Name and Address:
Student's Phone Number:
Student's School:

Name and place of employment of school employee accused of injuring/abusing the student:

Allegation is of:  ______ Physical Abuse     _____ Sexual Abuse**

**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 the investigation. Please indicate "yes" if the parent/guardian wishes to exercise this right:

_____ Yes     _____ No     Telephone Number:

Please describe what happened (Include date, time and where the incident took place, if known. If physical abuse is alleged, also state the nature of the student's injury. Attach an additional sheet, if needed.)

Were there any witnesses to the incident or are there students or persons who may have information about the incident? _____ Yes     _____ No

If yes, please list by name (if known) or classification (Example: third grade class, fourth period geometry class):

Complainant's Signature:
Complainant's Relationship to Student:

Please return this completed, signed form to the Level I Investigators:

  • 504 Compliance Coordinator

Address: 2999 N 10th Street, Marion IA 52302
Fax: 319-377-9252

Related Policy (Code#): 105.1
Reviewed 9/14; 3/17
Revised: 6/20