Joint Jerome School District #261

Sexual Harassment Report Form

(Report complaints to the building principal or district superintendent)

General Statement of Policy Prohibiting Sexual Harassment

Jerome School District #261 maintains a firm policy against all forms of discrimination based upon sex. Sexual harassment against students or employees is sex discrimination. All persons are to be treated with respect and dignity. Sexual advances or other forms of personal harassment by any person, male or female, which creates an intimidating hostile or offensive environment, will not be tolerated under any circumstances.

Complainant

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Home Address

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Work Address

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Home Phone

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Work Phone

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Date of Alleged Incidents(s)

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Name of person you believe

sexually harassed you:

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Witnesses

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Where did the incident(s) occur?

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Describe the incident(s) as clearly as possible, including such things as: what force, if any was used; any verbal statements (i.e. threats, requests, demands, comments, etc.); what, if any, physical contact was involved; what you did to avoid the situation, etc (attach additional pages if necessary.)

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This complaint is filed based upon my honest belief that I have been sexually harassed. I hereby certify that the information I have provided in this complaint is true, correct and complete to the best of my knowledge and belief.

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Complainant Signature Date

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Received by: Date

I understand that any communication of this incident may not be considered privileged information. The person to whom the communication is made, may have duty to report the incident either to his/her supervisors or to other authorities.