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403.15-E - Student Abuse Report Form




Please complete the following as fully as possible. If you need assistance, contact the Level I investigator in your school.

Please Print

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