Title IX Report

Custom Form

Title IX Report*
"Supportive efforts or a remedy can be offered once the situation has been investigated."
I am a:
Name (Optional, but helpful):
Address (Optional):
E-Mail (Optional)
Daytime Phone (Optional):
Student Victim Name:
Victim's School:
Victim's Grade:
Alleged Offenders Name and Grade (If known; If more than one, include all names separated by commas):
Date & Time of Incident (If known; specify AM or PM):
Month - Day - Year Time
Has this incident been reported to anyone yet? If so, to whom (teacher, parent, etc.):
Were there any witnesses?:
Yes
No
Please provide their names (If known):
Did you witness the harassment firsthand?:
Yes
No
Describe what happened and how long it has occurred:
Additional Information (Optional):

Law Enforcement should be contacted if you are aware of:
Death threats or threats of other forms of violence to a person or property
Excessive intimidation or extortion
Threats of intimidation that involve any form of bias or discrimination
Any evidence of sexual exploitation or abuse

Security Measure

Month	-	Day	-	Year	Time

Title IX Report*