Investigation ID Number:
(campus initials – date of incident/complaint – student first/last initials)

CAMPUS: ITU_____ AUT_____ HP_____  HA_____

STUDENT(s) INVOLVED IN INCIDENT (must include: name – DOB – SS#):

DATE and TIME OF INCIDENT / ALLEGATION / COMPLAINT:

DATE INVESTIGATION INITIATED – COMPLETED:

Initiated: Completed:

INCIDENT LOCATION/BUILDING:

INVESTIGATOR(s) / REPORTER(s) (must include: name – title):

STAFF INVOLVED IN INCIDENT (must include: names – titles – DOB – SS#):

WITNESSES / OTHER PARTICIPANTS (must include: names – titles):

SHORT DESCRIPTION OF ALLEGATION (state what prompted the investigation):

INTERVIEWER(S) (must include: names – titles – name of subject interviewed):

DETAILED SUMMARY OF FACTS LEARNED IN THE INVESTIGATION:

RELEVANT STAFF HISTORY (work performance, prior 51A involvement, etc.)

POLICY/PROTOCOL REVIEW (list any issues related to staffing ratios, communication, compliance, etc.)

CONCLUSIONS (Hillcrest’s judgment on the matter as a result of the investigation.)

CORRECTIVE / PREVENTIVE ACTIONS AND/OR RECOMMENDATIONS:

RELEVANT ATTACHMENTS (All documentation related to investigation activities):

NOTIFICATIONS (must include: name – agency/relationship – date – by whom):

STUDENT DEBRIEFING(s) (If appropriate – must include: student – date – by whom)

EXTERNAL FINDINGS or ADDITIONAL COMMENTS:

SIGNATURES:

INVESTIGATOR / REPORTER: _________________________________________________/___/__
(signature) (date)

INVESTIGATOR / REPORTER: _________________________________________________/___/__
(signature) (date)

INVESTIGATOR / REPORTER _________________________________________________/___/__
(signature) (date)

PROGRAM DIRECTOR: _________________________________________________/___/__
(signature) (date)

EXECUTIVE VICE PRESIDENT: _________________________________________________/___/__
(signature) (date)
SC 9/11

FORMAL WITNESS STATEMENT
Please answer all of the following questions that apply to the incident/complaint:

1. What was the exact time/day of the incident? If you are unsure of the exact time, use other indicators (i.e. after lunch, before 3rd period, etc.)
   2. What was the activity leading up to the incident? (i.e. we were getting ready to transition to the dorm; we were cleaning up the baseball equipment, etc.)
   3. Exactly what did you see, hear, feel, etc.? Remain factual – do not include opinions or what you think may have happened. Be specific (e.g. which hand was the bat in? what were the exact words spoken? Etc.)
   4. Where did the incident occur? Be specific as to the location of the room, area, field, etc.
   5. How did the incident end? (i.e. supervisor walked out of the dorm with student, student went into room for a time out, etc.)
   6. Name all others that may have seen or heard the incident (staff and students). What was their exact proximity to the incident? Did some leave or come into the area during the incident? Be specific.
   7. Sign and date this statement at the bottom.