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 Abuse _____ Sexual Abuse**
Please describe what happed. Include date, time, and where incident took place if known. If physical abuse is alleged, also state the nature of the student's injuries. __________________________________________________________________________________________
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 be name (if known) or classification. 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 the investigation. Please indicate "Yes" if the parent/gaurdian wishes to exercise this right:
_____ Yes _____ No Telephone Number: ____________________________________________________________________
Reviewed: 9/14; 3/17
Related Policy (Code#): 403.15