Maltreatment of Students Reporting Form

Maltreatment information is confidential data.  Use this form only to report to MDE.


MDE 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)


Date Submitted ______ I.S.D. Name & Number ____________________________________________________________

Via:   Phone School Name__________________________ Address ____________________________________

Fax     City __________________ State _______ Zip _______   Phone Number (____)_________________

U.S. Mail Principal _________________________________________________________________________


REPORTER (Reporter is confidential under Minn Stat. § 626.556) Mandated ____ Non Mandated ____

Name______________________________ Title______________________________ Phone (____)____________________

Address______________________________________ City______________________ State_________ Zip______________

 

ALLEGED VICTIM

Name____________________________________ DOB____________  Grade _________  Gender:      ڤ Male   ڤ Female 

Special Education:  Y/N       Disability Description __________________________________ Ethnicity _________________ 

Address_______________________________________ City______________________ State_________ Zip___________

Parent/Guardian___________________________ Home Phone (____)_______________ Other Phone (____)___________  


ALLEGED OFFENDER

Name________________________________ Position _______________   DOB __________   Gender:  ڤ Male   ڤ Female  

Address_____________________________ City_______________ State ______ Zip________ Ethnicity _______________

Home Phone Number (____)__________________________ Other Phone (____)_________________________________


Type of Alleged Maltreatment   ڤ Physical Abuse ڤ Sexual Abuse ڤ Neglect

Injury   Yes            No ___    Description of Injury _________________________________________________________


Date of Incident ________ Time __________ Location______________ City _______________   County ______________

Witness Information: _________________________________________________________________________________


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








Police Notified:  ڤYes  ڤNo  Police Department ___________________ Contact ________________Phone (___)_____________

Please Fax Report to: Student Maltreatment Program – (651) 634-2277

Student Maltreatment Program, Division of Compliance & Assistance

1500 Highway 36 West, Roseville, Minnesota 55113-4266

Phone:   (651) 582-8546 Fax:   (651) 634-2277 3/4/08