Confidential Student Maltreatment Reporting Form (414. Policy)

    414. Form for Policy - Mandated Reporting of Child Neglect or Physical or Sexual Abuse

    MM slash DD slash YYYY

    REPORTER

    (Reporter is confidential under Minnesota Statutes, section 260E.)
    Address
    Mandated Reporter(Required)

    SCHOOL INFORMATION

    (Current Enrollment Location of Alleged Victim)
    Address

    ALLEGED VICTIM

    Address
    Sex
    MM slash DD slash YYYY
    Receives Special Education Services
    Alleged Victim is over the age of 18
    (If over 18, please provide the following contact information)
    Alleged Victim has a legal guardian
    Address
    Address

    ALLEGED OFFENDER

    MM slash DD slash YYYY
    Sex
    Home Address
    Licensed

    INCIDENT

    MM slash DD slash YYYY
    Time
    :
    Police Notified

    ALLEGED MALTREATMENT

    Alleged Maltreatment(Required)
    Injury(Required)
    Max. file size: 50 MB.
    Form Updated: November 2020
    This field is for validation purposes and should be left unchanged.

    minnesota department of education information

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