Minnesota Department of Education
CONFIDENTIAL DATA
Maltreatment of Minors by School Personnel Reporting Form
Date Submitted_______
School District Name & Number______________________________________________
School Name_____________________________________________________________
Address _________________________________________________________________
Principal ________________________________________________________________
School Phone Number (____)________________________________________________
REPORTER
Name_______________________________________________________________________
Title_________________________________________________________
Address_____________________________ City_____________________ State_________
Zip___________________
Phone Number (____)___________________________________________
(Reporter is confidential under Minn Stat. § 626.556)
ALLEGED VICTIM
Name____________________________________ DOB_____________ Grade______ Gender___________________
Special Education: Y/N Disability Category____________________________________________________________
Address________________________________ City__________________ State______________
Zip______________
Phone Number (____)_____________________________ Parent/Guardian___________________________________
ALLEGED OFFENDER
Name________________________________________________________________________
Title________________________________________________________________________
Address________________________________ City _________________ State__________
Zip__________________
Home Phone Number (____)_______________________ Work Phone (____)_________________________________
Type of Maltreatment__________________________________________________________________
Date of Incident_____________________________
Time of Incident________________________________________
Location_______________________
County______________________ City__________________________________
Witness____________________________________________
Phone Number(___)_____________________________
Witness____________________________________________
Phone Number(___)_____________________________
Summary of Incident:
_______________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
_______________________________________________________________________________
School Investigation Information Included: Yes_____
Date to be sent_____________
Were Police Notified: Y/N Date_______ Police Department___________________________________________
Contact Person__________________________________ Phone Number (____)_______________________________
Please Fax Report To: Attention Maltreatment of Minors Program – 651.634.2277
Maltreatment information is confidential data. Use this form only to report to MDE.