Confidential Student Maltreatment
           Reporting Form            

Date Submitted: _________________________                              MDE File #: ____________  (MDE staff use only)

REPORTER (name of person completing form)  Reporter is confidential under Minnesota Statutes, section 626.556.
Name: __________________________________  Title: ______________________  Phone: _________________  Mandated Reporter: Yes ___  No ___
Address: _________________________________________________  City: ____________________________  State: _______  Zip: ________________

SCHOOL INFORMATION
ISD #: _______  School District: ______________________________________________  Program Name: _____________________________________
School Name: ________________________________  Address: ______________________________  City: ______________________  Zip: _________
Principal/Director: _______________________________________________    Phone: ______________________________     (Ext):_______________
Transportation Company (if necessary): Contact: ________________________________________________   Phone: _____________________________

ALLEGED VICTIM (Complete one reporting form for each alleged victim)
Name: ________________________________  Address: _____________________  City: _________________________  State: ____  Zip: __________
Parent/Guardian: ____________________________    Phone: ____________________________  Alternate Phone: ______________________________
Gender: Male _____  Female _____     DOB: ______________________   Grade: ____________     Ethnicity: ________________________________
Special Education:  Yes ___  No ___  Disability Description: _____________________________________________  State Student ID: _____________

ALLEGED OFFENDER
Name: ______________________________________________  Position: __________________  DOB: ____________  Gender: Male ___  Female ___
Address: _________________________________________________  City: ____________________________  State: _______  Zip: ________________
Ethnicity: __________________________  Phone: ___________________________________  Alternate Phone: _________________________________
Licensed: Yes _____  No _____  If licensed, name of licensing board: _____________________________________   Folder #: _____________________

INCIDENT
Date: _____________________  Time: ____________________  Location (i.e. - bus, classroom): ____________________________________________
Address (if different than school): _____________________________________________________  County: ____________________________________
Witness Contact Information: _____________________________________________________________________________________________________
Police Notified:  Yes _____  No _____         Police Department: ______________________________________________________________________
Police Contact: _______________________________________     Phone: __________________________     Case No.: _________________________

Alleged Maltreatment:  Physical Abuse _____  Sexual Abuse _____  Neglect _____  Unknown _____     Injury: Yes ____  No ____ Unknown ____

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

Minnesota Department of Education
Student Maltreatment Program
1500 Highway 36 West, Roseville, MN 55113-4266
Reporting Line: 651-582-8546  Fax: 651-797-1601
Email: mde.student-maltreatment@state.mn.us
June 2016