Title IX - Sexual Harassment

Information About the Person Making This Report:

Name:
Address:
Phone Number:
Location:
I am a:	Student Parent/Guardian Employee Volunteer Visitor Other (Explain relationship to the district below)
If you are not the victim of the reported conduct, please identify the alleged victim's name:
The alleged victim is:	Your Child  Another Student  A District Employee Other (Please explain below)

Information about the person(s) you believe is/are responsible for the bullying, hazing, harassing, or other discrimination you are reporting.

What is/are the name(s) of the individual(s) you believe is/are responsible for the conduct you are reporting? (Please list at least one name and no more than 5)

The reported individual(s) is/are:

Student(s) Employee(s) Other (Explain Below)

Description of the Conduct You are Reporting

In your own words, please do your best to describe the conduct you are reporting as clearly as possible.

When did the reported conduct occur? (Please provide the specific date(s) and time(s) if possible):

Where did the reported conduct take place?

Please provide the name(s) of any person(s) who was/were present, even if for only part of the time.

Please provide the name(s) of any other person(s) that may have knowledge or related information surrounding the reported conduct.

Have you reported this conduct to any other individual prior to giving this report?

Yes No

If yes, who did you tell about it?

If you are the victim of the reported conduct how has this affected you?

 

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