Intermediate Unit 1 Discrimination/Harassment Incident Reporting Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Discrimination in any form is strictly prohibited by Intermediate Unit 1. All reports of discrimination/harassment will be promptly and equitably addressed.
• Title IX of the Education Amendments of 1972 (“Title IX”) specifically prohibits discrimination on the basis of sex in federally-funded education programs and activities and extends to employment.
• Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, and national origin.
• The Age Discrimination Act of 1975 prohibits discrimination based on age.
• Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act of 1990 prohibits discrimination against persons with disabilities.

It is the responsibility of the Intermediate Unit to ensure that all students and members of the IU1 community have a safe school environment. This includes ensuring that any incident of discrimination, harassment, or sexual misconduct is given immediate attention, including investigating the incident, taking appropriate corrective action, and providing students and staff with appropriate supportive resources. Complaints alleging discrimination or harassment will be taken seriously and handled in a prompt and equitable manner.

Name of Person Making the Report *

Address *

Phone Number *

School Building *

I am a : *

Student

Parent/Guardian

Employee

Volunteer

Visitor

Other:

If you are not the victim of the reported conduct, please identify the alleged victim: *

The alleged victim is: *

Your Child

Another Student

Employee

Other:

What is/are the name(s) of the individual(s) you believe is/are responsible for the conduct you are reporting? *

The reported individual(s) is/are: *

Students

School Employee

Other:

In your own words, please do your best to describe the conduct you are reporting as clearly as possible. *

When did the reported conduct occur? (Please provide the specific date(s) and time(s) if possible): *

Where did the reported conduct take place? *

Please provide the name(s) of any person(s) who was/were present, even if for only part of the time. *

Please provide the name(s) of any other person(s) that may have knowledge or related information surrounding the reported conduct. *

Have you reported this conduct to any other individual prior to giving this report? *

Yes

If yes, who did you tell about it? *

If you are the victim of the reported conduct, how has this affected you? *

I affirm that the information reported above is true to the best of my knowledge, information and belief. *

Yes

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Intermediate Unit 1. Report Abuse

Forms