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105.1-E Student Injury/Abuse by School Employee Reporting Form

Click here to download the Student Injury/Abuse Reporting Form


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

Student's Name and Address:
Student's Telephone 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:
Date:

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

  • Karla Christian, Chief Officer of Human Resources, Equity Coordinator,
    Title IX Coordinator, and Affirmative Action Coordinator
  •  Nathan Wear, Associate Superintendent and Equity Coordinator (Secondary Level)
  • ​Bob Read, Associate Superintendent and Equity Coordinator (Elementary Level)
  • Melissa Frick, Executive Director of Student Services and Special Education/Student Services Equity Coordinator

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


Related Policy : 105.1
Reviewed 9/14; 3/17; 3/23
Revised: 6/20; 10/23