Employee Incident Report Page 2
Download a blank fillable Employee Incident Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Employee Incident Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Page 2 of 2
C
A
O N F I D E N T I A L I T Y
G R E E M E N T
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.
By signing this agreement, I understand that:
1.
Confidentiality means that I cannot discuss any matter pertaining to any child abuse or neglect case, except as allowed by law. Pursuant to
§552a of Title 5, United States Code, the Family Education Rights and Privacy Act of 1974 (20 USC 1232g), or any other provision of law,
agencies of any Indian tribe, of any State, or of the Federal government that investigate and treat incidents of child abuse may provide
information and records to those agencies of any Indian Tribe, State, or any Federal Government that need to know the information in
order to perform their duties. For purposes of this section, Indian tribal government shall be treated the same as other Federal Government
entities.
2.
The legal requirements of confidentiality mean that I cannot discuss any matter pertaining to the Suspected Child Abuse and/or Neglect
Report I completed on this date with any member of my family, including parents, children, spouse, aunts, uncles, cousins, any school staff
or with another person unless they are allowed access to such information by law.
3.
If I do not keep substantiated and/or unsubstantiated child abuse and/or neglect cases confidential, I may be subject to disciplinary action
up to and including termination of my job as allowed by tribal or federal law or BIE policies and procedures.
(Required)
Signature of Mandated Reporter
Position/Title
Date
Witnessed by:
(Required)
Signature of School Principal/Administrator or Designee
Position/Title
Date
Notifications Tracking
Information on Person Making Notifications
BIE Notification
Date and Time of Report
(Required)
Person Contacted, Title, and Telephone Number
Verbal
Written
Contact
Contact
BIE Program Specialist
(SCAN)
SCAN Tracking Notes
Information on Person Making Notifications:
Full Name and Title of Individual Completing this Page (Required):
Date:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business