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2. Resident's Name (Nombre del Residente):*
3. Facility (Instalación):*
5. Date of alleged incident (Fecha del Presunto Incidente):
6. Time of alleged incident (Tiempo del Presunto Incidente):
8. Name of alleged abuser (Nombre del Presunto Abusador):
9. If name is unknown, description of abuser (Si nombre es desconocido, la descripción del abusador):
11. Description of alleged incident (Descripción del Presunto Incidente):*
13. Location of alleged incident (Lugar del Presunto Incidente):
15. Any other pertinent information (Alguna Otra Información Pertinente):
17. Your Name (Su Nombre):*
18. Relationship to Resident (Relación al Residente):
20. Your Phone Number (Su Número Telefónico):
22. Your Email Address (Su dirección de correo electrónico):*
24. Points to Remember:

    1. Third parties, including fellow residents, staff members, family members, attorneys, and outside advocates, shall be permitted to assist residents in filing requests for administrative remedies and shall also be permitted to file such requests on behalf of the resident. 

    2. If a third party, other than a parent or legal guardian, files such a request on behalf of a resident, the facility may require as a condition of processing the request that the alleged victim agree to have the request filed on his or her behalf, and may also require the alleged victim to personally pursue any subsequent steps in the administrative remedy process. 

    3. A parent or legal guardian of a resident shall be allowed to file a grievance regarding allegations of sexual abuse, including appeals, on behalf of such resident. Such a grievance shall not be conditioned upon the resident agreeing to have the request filed on his or her behalf. 

    4. All allegations involving criminal behavior will be forwarded to the Lake County Sheriff’s Office for investigation. 

    5. Filing a knowingly false report is criminal and will be forwarded to the Lake County Sheriff’s Office.

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26. 1. Receive an email copy of this form.
27. Email address

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28. Submit

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