Appendix B: Form for Reporting Sexual Misconduct with a Minor
REPORT OF SEXUAL MISCONDUCT WITH A MINOR
Name of person making report: ____________________________________
Position ____________________________________
Address ____________________________________
Telephone Number ___________________________
Date of Report ____________
Please state the name, address, position and telephone number (if known) of the person suspected or accused of sexual misconduct with a minor.
Name _____________________________
Position ___________________________
Address ___________________________
Telephone Number __________________
Please state the name, sex, age, address and telephone number of the child who has been or is suspected to be the victim of sexual misconduct or abuse.
Name _________________________________ Sex ______ Age _____
Address _______________________________
Telephone Number ______________________
Parents or Legal Guardians Name __________________________
Address _______________________________
Telephone Number ______________________
Please provide a description of the incident of sexual abuse, including the date, time and location of each act of sexual abuse.
(continue on separate page if necessary)
Please provide the names, positions, addresses and telephone numbers of all eyewitnesses or others having relevant information.
Name ___________________________
Position _________________________
Address _________________________
Telephone Number_________________
Name ___________________________
Position _________________________
Address _________________________
Telephone Number ________________
(continue on separate page if necessary)
Please provide any additional information bearing on the incident that may be helpful to an investigation.
Deliver completed report to any of the following:
1. Your Parish Priest or the Bishop
2. Anne Kresin, LSCSW
Victim Assistance Coordinator
Catholic Diocese of Salina
Confidential Mailing Address:
P.O. Box 2984
Salina, KS 67402
Phone: 785-825-0865