Employee Incident
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(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 Check One: First Middle 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 Initials of Mandatory Reporter: YES NO Page 2 of 2 CONFIDENTIALITY AGREEMENT To be read and signed by Mandated Reporter: In accordance with the Indian Child Protection and Family Violence Prevention Act, the identity of any person making a report of suspected child abuse or neglect shall not be disclosed, without the consent of the individual, to anyone other than a court of competent jurisdiction, employees of an Indian tribe, State, or the Federal Government who need to know the information in order to perform their duties..
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