Title IX Report Form

DISCRIMINATION/HARASSMENT/RETALIATION REPORT FORM

Note: For purposes of Title IX sexual harassment, this Report Form serves initially as an informal report, not a formal complaint of Sexual Harassment under Title IX.

The Board declares it to be the policy of this district to provide a safe, positive learning and working environment that is free from discrimination and harassment, including sex-based harassment and retaliation. If you have experienced, or if you have knowledge of any such actions, we encourage you to complete this form. The Title IX Coordinator will be happy to support you by answering any questions about the report form, reviewing the report form for completion and assisting as necessary with completion of the report.

Retaliation Prohibited

The district, its employees and others are prohibited from intimidating, threatening, coercing or discriminating against you for making this report. Please contact the Title IX Coordinator immediately if you believe retaliation has occurred.

Confidentiality

Confidentiality of all parties, witnesses, the allegations and the filing of a report shall be handled in accordance with Board policy, procedures and the district’s legal and investigative obligations. The school will take all reasonable steps to investigate and respond to the report, consistent with a request for confidentiality, as long as doing so does not preclude the school from responding effectively to the report. If you have any questions regarding how the information contained in this report may be used, please discuss them with the Title IX Coordinator prior to filing the report. Once this report is filed, the district has an obligation to investigate the information provided.

Please fill out the contact form below, or submit a filled out copy of the Title IX form, found on our board policy page. The completed form can be uploaded below. Please make sure to fill out the signature at the end of the form.

Title IX report form upload

If you've filled out a Title IX report from the board policy, please upload it here.

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I. Information About the Person Making This Report:

Your Name

Answer required for "Your Name"

Address:

Answer required for "Address:"

Phone Number:

Answer required for "Phone Number:"

Assigned School Building(s):

Answer required for "Assigned School Building(s):"

Are you a(n):*

If other, please explain relationship to the district, education program, or activity.

Answer required for "Are you a(n):"

Employee

Volunteer

Visitor

Other:

If you're not the victim of the reported conduct, please identify the alleged victim:

Answer required for "If you're not the victim of the reported conduct, please identify the alleged victim:"

The alleged victim is:

If other please explain relationship to the alleged victim.

Answer required for "The alleged victim is:"

Another Employee

Student

Other:

II. Information About the Person(s) You Believe is/are Responsible for the Conduct You are Reporting

What is/are the name(s) of the individual(s) you believe is/are responsible for the conduct you are reporting?

Answer required for "What is/are the name(s) of the individual(s) you believe is/are responsible for the conduct you are reporting?"

The reported individual(s) is/are:

If other, please explain relationship to the district.

Answer required for "The reported individual(s) is/are:"

Employee(s)

Student(s)

Other:

III. 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:

Answer required for "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):

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

Where did the reported conduct take place?

Answer required for "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.

Answer required for "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.

Answer required for "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?

Answer required for "Have you reported this conduct to any other individual prior to giving this report?"

Yes

Other:

If yes to the above question, who did you tell about it?

Answer required for "If yes to the above question, who did you tell about it?"

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

Answer required for "If you are the victim of the reported conduct, how has this affected you? "

Is there anything else you wish the Title IX Coordinator to know at this time?

Answer required for "Is there anything else you wish the Title IX Coordinator to know at this time? "

Signature of Person Making the Report*

Signature Required

Please fix the highlighted areas below before submitting.

Title IX Report Form