Santa Clara Unified School District Title IX Incident Report Form
You may submit an anonymous and confidential report of sex discrimination, including sexual harassment or sexual violence, by using this form. This is one of many formats you can use to report an incident. Please report in a format with which you are most comfortable but please, if you see something that is some form of harassment or discrimination, say something.

Fill in the information requested below, to the best of your ability, and click the blue SUBMIT button when you are finished. This information will be received confidentially by the District’s Title IX Coordinator. Her duties include reviewing and coordinating the District’s response to Title IX reports and complaints. You may contact her via email at title9@scusd.net or via phone at 408-423-3509.

Once the Title IX Coordinator receives your anonymous report, she will look into the matter and contact you within 10 days if you have requested to be contacted and if you have provided your contact information in the form below. If you have chosen not to provide your identity or contact information, the Title IX Coordinator will review the information you submitted and determine the available next steps in order to address the matter.

The Title IX Coordinator receives the responses for this form. You are welcome to remain anonymous in reporting an incident.  However, the more information you can provide, the better SCUSD may be able to respond to a situation.

SCUSD takes all reports seriously.  Please do not abuse this reporting format.  Si necesita este formulario en español, haga clic aquí.  
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Today's date: *
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How did you learn about the incident? *
What day did the incident occur? *
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At approximately what time did the incident occur? *
Time
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Where did the incident occur? *
Did the incident occur at a SCUSD sponsored event (whether on or off campus)? *
School where you (or the victim/survivor, if you are only reporting the incident) are a student *
Who was present when the incident occurred? *
Name the person (or group) to whom the incident happened. *
What is the gender of the person(s) to whom this incident happened? *
The person(s) who is (are) believed to have caused the incident was (were): *
Required
Name(s) or descriptions of the person or people believed to have caused the incident: *
What is the gender of the person(s) believed to have caused the incident? *
What is/was the relationship, if any, between the victim/survivor and the person(s) who caused the incident? *
People who may have knowledge of relevant facts and a short summary of what they may know. Include contact information if available. *
What other information can you share about the incident?
Please provide any additional information you would like SCUSD to consider in addressing the report (for example, confidentiality concerns, involvement with other individuals or agencies, pending investigations, prior complaints).
Would you like the Title IX Coordinator to contact you? *
[Optional] If you answered "yes" above, please provide your name and a phone number or email address at which you may be reached.
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