3290F: Sexual Harassment/Intimidation Reporting Form

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                                                                                                


Transcript Request Form

Please initial below to acknowledge that you are the student named above and that you have reviewed the information above and agree that it is accurate. By initialing below you endorse this document as legally binding in accordance with the e-sign bill S.761 and release the below initials in lieu of a signature.
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