Jerome Joint School District No. 261

STUDENTS 3290F

Harassment 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________________________________________________