Report of Sexual Misconduct With a Minor

Report of Sexual Misconduct With a Minor

Diocese of Dodge City
Name of Person Making the Report*

First NameLast Name
Position

Address

Date of ReportState / Province

Phone Number
Email
example@example.com
Please state the name, address, position and telephone number (if known) of the person suspected or accused of
sexual misconduct with a minor.
Name *

First NameLast Name
Position

Address

Date of ReportState / Province

Phone 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 *

First NameLast Name
Address

Address

SexAge

Phone Number
Parents or Legal Guardians Name

Address

TelephoneAge

Phone Number
Please provide a description of the incident of sexual abuse, including the date, time and location of each act of sexual abuse.
Add text here.
Please provide the names, positions, addresses and telephone numbers of all eyewitnesses or others having relevant information.
Name

First NameLast Name
Address

Position

Address

PhoneState / Province

Postal / Zip Code
Name

First NameLast Name
Address

Position

Address

PhoneState / Province

Postal / Zip Code
Additional Persons Involved
Please provide any additional information bearing on the incident that may be helpful to an investigation.
Add additional information here.
You always have the right to directly contact the Department of Children and Families. Their hotline number is 1-800-922-5330.

This form once submitted will be handled by Mr. Charles Befort of the Diocesan Review Board
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