Legal Reporting Abuse Form

LEGAL REPORTING ABUSE FORM

This Legal Reporting Abuse Form (the "Form") is entered into by Reporter: of Address: and Reporting Entity: of Address: effective on the date this Form is signed by the parties below.

RECITALS

WHEREAS, Reporter seeks to report conduct that Reporter believes constitutes abuse, harassment, discrimination, neglect or other wrongful acts as defined under this Form; and

WHEREAS, Reporting Entity maintains procedures for receiving, documenting, investigating and remediating reports of abuse and requires a signed report to initiate an investigation and to document chain of custody for evidence; and

WHEREAS, the parties desire to set forth the terms, certifications, and acknowledgements related to submission, handling, and investigation of the reported abuse.

NOW THEREFORE, in consideration of the parties' mutual covenants and the reporting and investigatory processes described below, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form: "Abuse" means conduct that reasonably may constitute physical abuse, sexual abuse, emotional or psychological abuse, financial exploitation, neglect, harassment, discrimination, or other unlawful or prohibited conduct under applicable law or entity policy. "Report" means the content submitted by Reporter pursuant to Section 2 below. "Confidential Information" means nonpublic information obtained or generated in the course of receiving and investigating the Report, subject to the confidentiality and disclosure provisions set forth in this Form.

2. SUBMISSION OF REPORT

Reporter provides the following factual information concerning the alleged abuse. Reporter acknowledges that the Reporting Entity will rely on the accuracy of the information provided to initiate and conduct an investigation.

Physical Abuse
Sexual Abuse
Verbal/Emotional Abuse
Financial Exploitation
Neglect
Harassment/Discrimination
Other (specify):

3. REPORTER CERTIFICATION

Reporter certifies under penalty of perjury that, to the best of Reporter's knowledge, the information provided in this Form is true, accurate and complete. Reporter understands that knowingly making a false statement may result in civil or criminal liability under applicable law.

Reporter Certification I certify that the information set forth above is true and correct to the best of my knowledge.

4. INVESTIGATION, PRESERVATION, AND CONFIDENTIALITY

Upon receipt of this Form, Reporting Entity shall promptly record the Report, preserve relevant evidence, and commence a timely, thorough, and impartial investigation consistent with applicable law and entity policy. Reporting Entity will take reasonable interim measures to protect involved persons as necessary, which may include separation, temporary reassignment, or other protective actions.

To the extent permitted by law, the identity of Reporter and the contents of the Report shall be treated as Confidential Information. Notwithstanding the foregoing, Reporting Entity may disclose Report content and Reporter identity as necessary to conduct the investigation, to comply with legal process, to protect the safety of individuals, or as required by law.

5. INTERIM RELIEF, REMEDIES, AND LEGAL RIGHTS

Reporting Entity's obligations under this Form are administrative and investigatory and do not waive or limit the rights of Reporter to pursue any administrative, civil, or criminal remedies available under law. Nothing in this Form limits Reporting Entity's obligation to report suspected criminal activity to law enforcement where required by law.

6. NOTICES

Any notice required or permitted under this Form shall be in writing and delivered to the addresses provided below by hand, certified mail, or other delivery method providing proof of delivery.

7. REPRESENTATIONS AND WARRANTIES

Each party represents and warrants that it has full authority to execute this Form and that the individual signing on behalf of a party is authorized to bind that party. Reporter further represents that Reporter has not omitted material facts of which Reporter is aware and that Reporter will cooperate in good faith with any investigation.

8. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Form shall be governed by and construed in accordance with the laws of the state or jurisdiction in which the Reporting Entity maintains its principal place of business, without regard to conflict of law principles. This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, and communications. If any provision of this Form is held invalid, illegal or unenforceable, the remaining provisions shall remain in full force and effect.

9. AMENDMENT; WAIVER; COUNTERPARTS

No amendment, modification, or waiver of any provision of this Form is effective unless in writing and signed by both parties. No failure or delay by a party in exercising any right under this Form constitutes a waiver of that right. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

10. INVESTIGATIVE COOPERATION

Reporter agrees to cooperate reasonably and fully with Reporting Entity's investigation, including providing supplemental statements, producing evidence, and making self available for interviews as requested. Reporter understands that failure to cooperate may affect the scope and outcome of the investigation.

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