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ADMINISTRATIVELY RESTRICTED
E m plo y e e I n c i d e n t R e p or t
Page 1 of 2
Date of Report:
Time:
Reporting School:
School Phone Number:
Name of Child:
D.O.B.:
Last First Middle
Sex:
Age:
Grade:
Teacher:
Parent(s)/Legal Guardian(s) Names:
Mailing Address:
Location of Home:
Home Telephone:
Work No. (Mother):
Work No. (Father):
Date of Alleged Incident:
Time:
[ ] a.m. [ ] p.m.
Location of Alleged Incident:
Check all that apply:
Discourteous conduct involving a student by an employee:
[ ] Using inappropriate language
[ ] Making inappropriate comments of a nonsexual manner
[ ] Calling names insulting or humiliating a child
[ ] Shouting or cursing
[ ] Rude, boisterous play that adversely affect production, discipline, or morale of a student
[ ] Use of abusive, demeaning, degrading, or insulting language
[ ] Quarreling or inciting a quarrel
[ ] Other:
Describe in Student’s/Staff’s Own Words His/Her Account Of Event(s):
Full Name(s) of Potential Witness(es):
Phone Number(s):
Full Name of Alleged Offender:
Last First Middle
Check One:
[ ] BIE Employee
PositionTitle:
[ ] BIE Contractor/Consultant
[ ] Other (specify):
Full Name and Title of Mandatory Reporter:
Signature (Required): Date:
Full Name of School Principal/Administrator or Designee:
Signature (Required): Date:
Has Mandatory Reporter Requested Protection of His or Her Identity? [ ] YES [ ] NO
Initials of Mandatory Reporter: