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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 |
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Minnesota Department of Education staff
use only |
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Intake
Person |
MDE
File # |
Investigator |
Date
Assigned |
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□ No Maltreatment □ No Jurisdiction □ I & R
□ Other (Please explain) |
Date
Reporter Notified: ___________ ____
Verbal ____ Written (Attach written correspondence) |
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PSN
Date: _____________________ □ Verbal □ Written |
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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
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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) |
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Police
Notified: □ Yes □ No
Police Department _________________________ Contact
_________________________ Phone________________ |