2018-19 Northeastern Harassment, Intimidation, Bullying, and Title IX Referral Form
The Northeastern Local School District prohibits discrimination, harassment, intimidation, and bullying in all forms, including on the basis of a student's actual or perceived race, color, national origin, ethnicity, religion, sex, gender (including nonconformity with gender stereotypes, gender identity, and gender expression), sexual orientation, and disability, or on the basis of a person's association with a person or group with one or more of these actual or perceived characteristics. If you or someone you know has experience harassment, intimidation, or bullying at school for any reason, you may make a referral to have the incident (s) investigated by the District. Any student, parent/guardian, or school employee may complete this form and return it to any school employee. Alternatively, you may make a verbal or other written complaint to any school employee. Any school employee who receives a completed referral form or any other written or verbal complaint will immediately report the complaint to the Anti-HIB Building Coordinator to handle the harassment complaints. The designated school official will investigate and resolve the complaint under the District's policies and regulations, and consistent with all applicable federal and state laws. Contact information for the Anti-HIB District Coordinator and the Anti-HIB Building officials can be found in the Student Handbook.

The District will respect the privacy of students to the extent permitted by District policy and state and federal law. Retaliation against any individual who makes a complaint or who participates or assists in an investigation of harassment, intimidation, or bullying is strictly prohibited. Please provide as much information as possible. All requested information is optional.

If you have any questions before submitting your complaint, please contact:

District Anti-(HIB) Harassment, Intimidation, and Bullying Coordinator: Mr. Steve Linson, Director of Pupil Personnel/937-325-7615; stevelinson@nelsd.org

Northeastern High School Building HIB Coordinator: Mr. Todd Justice/937-328-6575; toddjustice@nelsd.org

Kenton Ridge High School Building HIB Coordinator: Mr. Rob Linkhart/937-390-1274; robertlinkhart@nelsd.org

Northridge Middle School Building HIB Coordinator: Mr. Gary Miller/937-399-2852; garymiller@nelsd.org

South Vienna Middle School Building HIB Coordinator: Mr. Zach Dobbelaere/937-346-0880; zachdobbelaere@nelsd.org

Northridge Elementary School Building HIB Coordinator: Mr. Rob Shaffer/937-342-4627; robshaffer@nelsd.org

Rolling Hills Elementary School Building HIB Coordinator: Mr. Drew Snyder/937-399-2250; drewsnyder@nelsd.org

South Vienna Elementary School Building HIB Coordinator: Mrs. Denise Jones/937-399-2250; denisejones@nelsd.org

Date of referral *
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Name of person making the referral *
Your answer
Phone number *
Your answer
Email address *
Your answer
I am a ... *
Required
Referral Information *
Please provide the name(s) of all persons (including yourself, if applicable) who were the target of harassment, intimidation, bullying, or retaliation.
Your answer
Referral Information *
Please provide the name (s) and/or descriptions of all individuals (students, school employees, school visitors, or others) who engaged or participated in the alleged harassment, intimidation, bullying, or retaliation. (if known)
Your answer
Description of Incident *
Details about the incident (s); Names of witnesses, place of incident, and time of incident.
Your answer
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