Confidential Student Maltreatment

Reporting Form
Intake Person

Minnesota Department of Education staff use only

Investigator

MDE File #
No Maltreatment

No Jurisdiction

Date Submitted:

I&R

Date Assigned

Other (Please explain)

Verbal

PSN Date: ___________

Date Reporter Notified: ______________

__ Verbal
__ Written (Attach written correspondence)

Written

ISD#:

Email Form

School District:

School Name:

Program Name:

Address:

City:

Zip:

Principal/Director:

Phone:

Phone:

Transportation Information, if necessary: Contact:

(Ext):
Phone:

REPORTER (name of person completing form) Reporter is confidential under Minnesota Statutes, section 626.556.
Name:

Title:

Phone:

Address:

Mandated Reporter: Yes

City:

State:

No
Zip:

ALLEGED VICTIM (Complete one reporting form for each alleged victim)
Name:

Grade:

DOB:

Special Education: Yes

No

Disability Description:

Address:

Female

Ethnicity:
City:

Parent/Guardian:

Gender: Male

State:

Phone:

Zip:

Alternate Phone:

ALLEGED OFFENDER
Name:

Position:

Address:

DOB:

Gender: Male

City:

Ethnicity:

State:

Phone:

Female
Zip:

Alternate Phone:

INCIDENT
Date:

Time:

Location (i.e. - bus, classroom):

Address (if different than school):

Alleged Maltreatment: Physical Abuse

County:
Sexual Abuse

Neglect

Unknown

Injury: Yes

No

Unknown

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

Witness Contact Information:

Police Notified: Yes
Contact:

No

Police Department:
Phone:
Minnesota Department of Education
Student Maltreatment Program
1500 Highway 36 West, Roseville, MN 55113-4266
651-582-8546 Fax: 651-797-1601
Email: mde.student-maltreatment@state.mn.us

Case No.:

May 2013