Jt. Jerome School District No. 261

STUDENTS 3085F1

Sexual Misconduct Reporting Form for Students

School ___________________________________________________________Date ________________________

Student’s Name_________________________________________________________________________________

(If you feel uncomfortable leaving your name, you may submit an anonymous report, but please understand

that an anonymous report will be much more difficult to investigate. We assure you that we’ll use our best

efforts to keep your report confidential.)

Who was responsible for the harassment or incident(s)? ________________________________________________

_____________________________________________________________________________________________

Describe the incident(s): _________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Date(s), time(s), and place(s) the incident(s) occurred: _________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Were other individuals involved in the incident(s)? yes no

If so, name the individual(s) and explain their roles: ___________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Did anyone witness the incident(s)? yes no

If so, name the witnesses: ________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Did you take any action in response to the incident? yes no

If yes, what action did you take? ____________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Were there any prior incidents? yes no

If so, describe any prior incidents: __________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Signature of complainant_________________________________________________________________________

Signatures of parents/legal guardian________________________________________________________________

Procedure History:

Adopted on: 12/15/2020