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 that is some form of harassment or discrimination, 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 SCUSD may be able to respond to a situation.

SCUSD takes all reports seriously. Please do not abuse this reporting format.
Today's date: *
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School where you are a student (or school where student for whom you are reporting goes) *
Name (optional)
Your answer
Contact information (optional)
Your answer
How did you learn about the incident? The incident *
Required
When did the incident occur? *
Your answer
Where did the incident occur? *
Your answer
Who was present when the incident occurred? *
Your answer
Name the person (or group) to whom the incident happened. *
Your answer
What other information can you share about the incident?
Your answer
The person (or group of people) who is (are) believed to have cause the incident were:
Name(s) or descriptions of the person or people believed to have cause the incident: *
Your answer
People who may have knowledge of relevant facts and a short summary of what they may know. Include contact information if available. *
Your answer
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, pending investigations).
Your answer
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