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: _____________________________________________________________________
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Student's telephone no.: ______________________________________
Student's school: ____________________________________________
Name and place of employment of employee accused of abusing student:
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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:
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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
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_____________________________________________________________________________________________
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.
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Your name, address and telephone number:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Relationship to student: ____________________________________________
___________________________________________ ________________________________________________
Complainant Signature Witness Signature
___________________________________________ ________________________________________________
Date Witness Name (please print)
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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 calendar days of filing this report unless the investigation is turned over to law enforcement.
