Investigation Complaint Form

Professional Standards Investigation Complaint Form

Reporting Incident

Location:  Date of Request: 

Site Administrator:  County Department: 

Location Phone:  Location Fax: 


Incident Information

Date and Time of Incident:  

Incident Occurred: On campus Off campus  Type of Incident: 

Name of Complainant: (Last Name)  (First Name)

Email address of Complainant: 

Complainant: 

 Area Supervisor
 Employee
 Parent
 Principal
 Student
 Supervisor
 Other 


Allegation

Name of accused: (Last Name)  (First Name) 

Position of Accused:  Contract Status: 

Explain the incident that occured. A short statement in your own words is sufficient, however, you may email more information and documents if necessary.


Outside agency contacted:  Yes  No

List all

Name of Agency: 

Agency Contact Person:  Agency Phone Number: 

Name of Agency: 

Agency Contact Person:  Agency Phone Number: 

Name of Agency: 

Agency Contact Person:  Agency Phone Number: 

*Reports to DCF's Child Abuse Hotline are confidential and do not have to be acknowledged here.

By typing your name you are signing this document and acknowledging everything submitted in this form is correct to the best of your knowledge.

Name:  Date: 



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