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Title IX Incident Report Form

The purpose of this Title IX grievance form is to gather the essential basic facts of the alleged actions in order that, prompt and equitable resolutions of complaints based on sex discrimination, including complaints of sexual harassment or sexual violence, in violation of Title IX of the Education Amendments of 1972 (“Title IX”) can be resolved as expediently and appropriately as possible. This form only applies to complaints alleging discrimination prohibited by Title IX (including sexual harassment and sexual violence).

INSTRUCTIONS:

Individuals alleging Title IX discrimination and requesting review are required to complete this form.  It will be submitted to the appropriate administrator as soon as possible after the occurrence of the alleged discrimination.

Contact Information

Student Grade*
Answer Required
Are there any witnesses to this matter? If yes, please identify the witnesses by adding their names to the 'other' block*
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Did you discuss this matter with any of the witnesses identified above? If yes, please identify the person to whom you have spoken, the date you spoke and the method of communication you used by adding the information to the 'other' block.*
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Have you spoken to any administrator(s) or other District employee(s) about this matter? If yes, please identify the person to whom you have spoken, the date you spoke and the method of communication you used by adding the information to the 'other' block.*
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PLEASE ATTACH ANY STATEMENTS, NAMES OF WITNESSES, REPORTS, OR OTHER DOCUMENTS WHICH YOU FEEL ARE RELEVANT TO YOUR COMPLAINT.
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or drag it here.
I certify that the foregoing information is true and correct.*
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Confirmation Email