Gooding Joint School District No. 231

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                                                                                                

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