Investigation ID Number: ____________________
(campus initials – date of initiation – student first/last initials)
I. Immediate Response/Fact Finding to Complaint/Incident:
YES N/A
❑ ❑ Obtain sufficient documentation of allegation/incident including statements, incident reports, etc.
❑ ❑ Obtain written statement from staff suspected of misconduct.
❑ ❑ Notify Executive Vice President and/or Vice President of Residential Programs of complaint/incident.
❑ ❑ Suspend alleged staff (with or without pay – depending on initial evidence).
❑ ❑ Formal Witness Statements from all staff witnesses (signed and dated).
❑ ❑ Interview summaries from all student witnesses – when appropriate (signed and dated).
❑ ❑ Document video surveillance review and save relevant material on compact disc.
❑ ❑ Gather relevant records, schedules, logs, medical documents, etc.
❑ ❑ Other investigatory activity (please specify):
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II. Notifications – Within 24hrs
YES N/A
❑ ❑ Report to DCF local screening unit (or state hotline if evening/weekend).
❑ ❑ Submit requested initial documentation to DCF.
❑ ❑ Call DEEC Licensor (must talk with a person).
❑ ❑ Submit EEC Employee Information Checklist (one for each staff alleged to have exhibited misconduct) and other requested documentation.
❑ ❑ Call/leave message for DESE liaison that Form 2 will be sent.
❑ ❑ Fax Form 2 (one for each student mistreated) along with required information to contact at Malden DESE office. (See DESE contact information for required information)
❑ ❑ Notify student’s legal guardian.
❑ ❑ Notify student’s family when appropriate.
❑ ❑ Other notification procedures specific to student’s funding/referral source.
❑ ❑ Notification to the JOINT COMMISSION (sentinel events only – CEO approval required)
❑ ❑ Other notifications completed (please specify):
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III. Internal Investigation Completion – Within 10 Business Days
YES N/A
❑ ❑ Internal Investigation Conclusion
❑ ❑ Corrective/Preventative Action plan
❑ ❑ Obtain investigator(s), Program Director/Program Manager, and Executive Vice President and/or Vice President of Residential Programs signatures.
❑ ❑ Submit copy of Internal Investigation Form and appropriate attachments to DEEC.
❑ ❑ Submit copy of Internal Investigation Form and appropriate attachments to DESE.
❑ ❑ Submit original Internal Investigation Form and appropriate attachments to Executive
Vice President.
IV. Incident Closure:
YES N/A
❑ ❑ Obtain documentation of DCF closure. Submit original to Executive Vice President and/or Vice President of Residential Programs and copies to DEEC and DESE.
❑ ❑ Obtain documentation of DEEC closure. Submit original to Executive Vice President and/or Vice President of Residential Programs and a copy to DESE.
❑ ❑ Obtain documentation of other investigating agency’s closure and submit to
Executive Vice President and/or Vice President of Residential Programs.
❑ ❑ Attach any requirements for further action and respective progress.
Additional Tasks/Comments:
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CASE CLOSURE AUTHORIZATION:
______________________________ ____________________
Signature Date