Confidential

Student Maltreatment Reporting Form

Division of Compliance and Assistance

1500 Highway 36 West

Roseville, Minnesota 55113-4266

Phone: (651) 582-8546 FAX: (651) 634-2277

 

Minnesota Department of Education staff use only

Intake Person

MDE File #

Investigator

Date Assigned

 

No Maltreatment No Jurisdiction I & R Other (Please explain)

Date Reporter Notified: ___________

____ Verbal

____ Written (Attach written correspondence)

PSN Date: _____________________ Verbal Written

 

Via:

 

Fax

Phone

U.S. Mail

Email:

 

Date Submitted ___________ School District Name __________________________________ School District Number ___________

 

School Name ___________________________________________ Address ______________________________________________

 

City ____________________________________________ Zip _______________ Phone Number _______________________

 

Principal ___________________________________________________ Phone Number ______________________________

 

 

 

REPORTER (name of person completing form) Reporter is confidential under Minnesota Statute 626.556

Name ______________________________________ Title ________________________ Phone __________________ Mandated Reporter: Yes No

Address __________________________________________ City _______________________ State _______ Zip ________________

 

ALLEGED VICTIM

Name _________________________________________________ DOB _________________ Grade ___________ Gender: Male Female

Special Education: Yes No Disability Description _____________________________________________ Race ____________________

Address ____________________________________________________________ City _______________________ State _______ Zip ____________

Parent/Guardian _________________________________________________ Home Phone __________________ Other Phone ____________________

 

ALLEGED OFFENDER

Name ___________________________________________________ Position __________________ DOB ___________ Gender: Male Female

Address _________________________________________________ City _____________________ State _____ Zip _________ Race ____________

Home Phone ____________________ Other Phone ____________________

 

INCIDENT

Date__________ Time __________ Location/Address (if different than school)______________________________________________________

Type of Alleged Maltreatment: Physical Abuse Sexual Abuse Neglect Unknown Injury: Yes No Unknown

Witness Information___________________________________________________________________________________________________________

Description of Incident and Injury: (please attach additional page if needed)

 

 

 

 

 

 

 

 

 

 

Police Notified: Yes No Police Department _________________________ Contact _________________________ Phone________________