Santa Clara Unified School District Harassment/Discrimination Incident Report 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, say something. The Title IX/Civil Rights Officer 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 able SCUSD may be able to respond to a situation.
Today's date:
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Name (optional):
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How may we contact you (optional)?
Contact Information (optional):
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Description of incident(s):
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Date(s) of incident(s):
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How did you learn about incident?
The incident happened to:
Name the person (or group) who the incident happened to:
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The person (or group of people) who is (are) believed to have caused the incident were:
Name the person (or group of people) who is (are) believed to have caused the incident:
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People who may have knowledge of relevant facts and a short summary of what they may know. Include contact information, if available.
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Please provide any additional information you would like the Santa Clara Unified School District to consider in addressing the report (for example, confidentiality concerns, involvement with other individuals or agencies, other pending investigations).
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