Student Discrimination/Sexual Harassment Incident Reporting Form

Targeted student

Report date

Program attended

Grade

Contact Information

Anonymous reporting person

Yes
No

If no, please provide name and contact information

Relationship to targeted student

Email

Phone

Alleged Incident

Date

Time

:

Location (check all that apply)

Person responsible for alleged discrimination/sexual harassment

Incident description - include details of event as observed by or reported to you.

Why do you think the incident occurred?

Results of Incident

Did a physical injury result from the incident?

Yes
No

If yes, please describe.

Was the targeted student absent from school as a result of the incident?

Yes
No

If yes, please describe reason and duration.

Other results?

Suggested Remedy

Please describe any corrective action you wish to see taken with regard to the incident.

Additional Authorities Contacted

Please provide any additional authorities contacted regarding this incident including dates of contact (Examples: school employee, parent, law enforcement agency, attorney, child protective services).

Other Information

Please provide any other information relevant to the incident.

Complainant signature

Date

For Office Use

Person Receiving Reporting Form:

Signature: ______________________________________________

Title: ____________________________________________________

Date: _______________________________

Parent/Guardian/Other Contacted

Please describe who, when, how:

Resolution

 Resolved  Unresolved
Please explain how and when resolution was determined:

Remitted to NWESD 189 Compliance Officer

Name: ___________________________________________________________

Date: _______________________________