Incident Report Suspected Abuse

Incident Report

Suspected Abuse

Name of Student Involved:                                                                                                                                                            

Birthdate:                                                  Male                          Female                                                                         

Parent or Guardian:                                                                                                     Phone:                                    

Address:                                                                                                         

Name of Alleged Abuser:                                                                                                                                                               

Date and Place of Incident or Incidents:                                                                                                               

Description of Misconduct (Attach report if necessary):                                                                             

Name of Witnesses (Complete witness report):                                                                                                                

1)                                                                                                                                                                                                                   

2)                                                                                                                                                                                                                   

Other Information (Inc. evidence of abuse, i.e. letters, photos, etc.):            

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature of Investigator                                                                                          Date

Witness Disclosure Form

Name of Witness:                                                                                                                                                                                

Position of Witness:                                                                                                                                                         

Date of Testimony, Interview:                                                                                                                                     

Description of Instance Witnessed (Attach report if necessary):

Other Information:

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature of Witness                                                                                                  Date