JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Central Greene School District Title IX Discrimination/Harassment Reporting Form
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Today's Date:
*
MM
/
DD
/
YYYY
Name of Person Making the Report:
*
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Location of Alleged Incident
*
Central Greene School District Administration Office
Waynesburg Central High School
Margaret Bell Miller Middle School
Waynesburg Central Elementary School
On School District property or event associated with the School District
Role:
*
Student
Parent/Guardian
Employee
Volunteer
Visitor
Other
If you are not the victim of the reported conduct, please identify the alleged victim:
*
Your answer
The alleged victim is:
*
Your Child
Another Student
Employee
Volunteer
Visitor
Other
What is/are the name(s) of the individual(s) you believe is/are responsible for the conduct you are reporting?
*
Your answer
The reported individual(s) is/are:
*
Student
School District Employee
Other
In your own words, please do your best to describe the conduct you are reporting as clearly as possible. *
*
Your answer
When did the reported conduct occur? (Please provide the specific date(s) and time(s) if possible): *
*
Your answer
Where did the reported conduct take place?
*
Your answer
Please provide the name(s) of any person(s) who was/were present, even if for only part of the time
*
Your answer
Please provide the name(s) of any other person(s) that may have knowledge or related information surrounding the reported conduct.
*
Your answer
Have you reported this conduct to any other individual prior to giving this report?
*
Yes
No
If yes, who did you tell about it?
*
Your answer
If you are the victim of the reported conduct, how has this affected you?
*
Your answer
I affirm that the information reported above is true to the best of my knowledge, information and belief.
*
Yes
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Central Greene School District.
Report Abuse
Forms
