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DISCRIMINATION/SEXUAL HARASSMENT/BULLYING/ HAZING/DATING VIOLENCE/RETALIATION REPORT FORM

 

 

The Board declares it to be the policy of this district to provide a safe, positive learning and working environment that is free from bullying, hazing, dating violence, sexual harassment and other discrimination, and retaliation. If you have experienced, or if you have knowledge of, any such actions, we encourage you to complete this form. The Title IX Coordinator will be happy to support you by answering any questions about the report form, reviewing the report form for completion and assisting as necessary with completion of the report. The Title IX Coordinator’s contact information is:

Position: Director of Student Services / Title IX Coordinator

Address:    Pennridge Administration Office, 1200 N. 5th Street, Perkasie, PA 18944

Email:        ejohnson@pennridge.org

Phone Number:  215-453-2785

Retaliation Prohibited

The district, its employees and others are prohibited from intimidating, threatening, coercing, or discriminating against you for filing this report. Please contact the Title IX Coordinator immediately if you believe retaliation has occurred.

Confidentiality

Confidentiality of all parties, witnesses, the allegations and the filing of a report shall be handled in accordance with applicable law, regulations, Board policy, procedures, and the district’s legal and investigative obligations. The school will take all reasonable steps to investigate and respond to the report, consistent with a request for confidentiality as long as doing so does not preclude the school from responding effectively to the report. If you have any questions regarding how the information contained in this report may be used, please discuss them with the Title IX Coordinator prior to filing the report. Once this report is filed, the district has an obligation to investigate the information provided.

Note: For purposes of Title IX sexual harassment, this Report Form serves initially as an informal report, not a formal complaint of Sexual Harassment under Title IX

 

 

Required

I. Information About the Person Making This Report:

Name:required
First Name
Last Name
I am a
Location of the alleged incident.
The alleged victim is:

II. Information About the Person(s) You Believe is/are Responsible for the Bullying, Hazing, Harassing or Other Discrimination You are Reporting

The reported individual(s) is/are:required

III. Description of the Conduct You are Reporting

In the boxes below, please describe what happened.

Share as much or as little detail as you feel comfortable providing. This may include specific words, actions, messages, or behaviors that caused harm or made you feel unsafe, uncomfortable, or targeted.

You may include experiences involving:

  • Racial or ethnic remarks

  • Sexual comments, sexual content, or sexual harassment

  • Comments or actions related to gender, gender identity, sexual orientation, religion, disability, or appearance

  • Threats, intimidation, repeated teasing, rumors, or social exclusion

  • Online or digital harassment (texts, social media, group chats, images, or videos)

Even if you are unsure whether the behavior qualifies as bullying, please describe it. What matters most is how the situation affected you or others.

Must contain a date in M/D/YYYY format (Must contain a date in M/D/YYYY format)
Have you reported this conduct to any other individual prior to giving this report?required
Affirmation of Person Making the Report
Signature of Person Making the Reportrequired
First Name
Last Name