NORTHFIELD CITY BOARD OF EDUCATION FILE CODE: 2224.1
Northfield, New Jersey X Monitored
X Mandated
Regulation X Other Reasons
DISCRIMINATION/SEXUAL HARASSMENT REPORT FORM
The board shall endeavor 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:
Address:
Email:
Phone Number:
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 or from complying with applicable law and board policy. 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.
I. Information About the Person Making This Report:
Name:
Address:
Phone Number:
School Building:
I am a:
□ Student □ Parent/Guardian □ Employee □ Volunteer □ Visitor
□ Other (please explain relationship to the district) If you are not the victim of the reported conduct, please identify the alleged victim:
Name:
The alleged victim is: □ Your Child □ Another Student □ A District Employee
□ Other: (please explain relationship to the alleged victim)
II. Information About the Person(s) You Believe is/are Responsible for the Bullying, Hazing, Harassing or Other Discrimination You are Reporting
What is/are the name(s) of the individual(s) you believe is/are responsible for the conduct you are reporting?
Name(s):
The reported individual(s) is/are:
- Student(s) □ Employee(s)
- Other (please explain relationship to the district)
III. Description of the Conduct You are Reporting
In your own words, please do your best to describe the conduct you are reporting as clearly as possible. Please attach additional pages if necessary:
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 □ No
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.
Signature of Person Making the Report Date
Received By Date
FOR OFFICIAL USE ONLY
This section is to be completed by the Title IX Coordinator based on reviewing the report with the complainant or other individual making the report.
The purpose of this form is to assist the Title IX Coordinator in gathering information necessary to properly assess the circumstances surrounding the reported conduct to determine if the allegations fall under the definition of Title IX sexual harassment and/or if the matter merits review and action under the Code of Student Conduct and/or other board policies. The Title IX Coordinator shall gather as much information as possible in cases of incomplete or anonymous reports (including those that may be received through the Safe2Say Something program) to assess the report.
Upon receipt of the report, the Title IX Coordinator shall promptly contact the complainant regarding the report to gather additional information as necessary, and to discuss the availability of supportive measures as described in board policy 2224.1 Title IX – Sex Based Discrimination. The Title IX Coordinator shall consider the complainant’s wishes with respect to supportive measures.
I. Reporter Information:
Name:
Address:
Phone Number:
School Building:
Reporter is a:
□ Student □ Parent/Guardian □ Employee □ Volunteer □ Visitor
□ Other (please explain relationship to the district)
If the reporter is not the victim of the reported conduct, please identify the alleged victim:
Name:
The alleged victim is: □ Reporter’s Child □Another Student □ Another Employee
□ Other: (please explain relationship to the alleged victim)
II. Respondent Information
Please state the name(s) of the individual(s) believed to have committed the reported violation:
Name(s):
The reported respondent(s) is/are:
□ Student(s) □ Employee(s)
□ Other (please explain relationship to the district)
III. Level of Report:
□ Informal □ Formal (see additional information below on Title IX formal complaints)
IV. Type of Report:
- Title IX Sexual Harassment □ Discrimination □ Retaliation □ Bullying
- Hazing □ Dating Violence □ Other
Nature of the Report (check all that apply):
- Race
- Age
- Color
- Creed
- Religion
- Sex
- Gender identity or expression
- Sexual Orientation
- Sexual Harassment (Title IX)
- National Origin
- Ancestry
- Marital Status
- Family status
- Relationship status (including marital, domestic partnership, or civil union status)
- Pregnancy
- Breastfeeding
- Disability
- Bullying
- Hazing
- Dating Violence
- Atypical hereditary cellular or blood trait, genetic information (including the refusal to participate in genetic testing or provide genetic information)
- Military service
- Other: ________________________________________________________________________
V. Reported Conduct
Describe the reported conduct below, including specific actions, dates, times, locations and any other details necessary to properly assess the reported incident(s).
How often did the conduct occur?
Is it being repeated? □ Yes □ No
Do the circumstances involve a student identified as a student with a disability under the Individuals with Disabilities Education Act or Section 504 of the Rehabilitation Act?
- No.
- Yes, please identify the student with a disability and contact the Director of Special Education.
Date Director of Special Education was contacted:
How has the conduct affected the alleged victim’s ability to fully participate in the school’s academic programs, activities or school employment?
What is the alleged victim’s relationship with the alleged respondent?
Insert names, descriptions, and/or contact information of individuals believed to have observed the conduct or who otherwise may have knowledge of the conduct and/or related circumstances.
Additional observations or evidence including pictures, texts, emails, video or other information submitted to the Title IX Coordinator.
VI. Safety Concerns
Are there physical health or safety concerns that may require Emergency Removal of or Administrative Leave for a respondent? (This requires an individualized safety and risk analysis as to whether there is an immediate threat to the physical health or safety of a student or other individual arising from the sexual harassment allegations justifying removal.)
- No.
- Yes, please describe:
VII. Other Reports
Has the conduct been reported to the police or any other agency?
- No
- Yes Date reported:
Agency:
VIII. Identification of Policies Implicated by Reported Conduct
Check all that apply:
- Policy 2224 Nondiscrimination/Affirmative Action
- Policy 2224.1 Title IX Sexual Harassment Affecting
- Policy 4111.1/4211.1 Nondiscrimination/Affirmative Action
- Policy 5131.1 Harassment, Intimidation and Bullying
- Policy 6121 Nondiscrimination/Affirmative Action
- Policy 6142.4 Physical Education and Health (Dating Violence)
To meet the definition of Title IX sexual harassment, the conduct must have taken place during a district education program or activity and against a person in the United States. An education program or activity includes the locations, events or circumstances over which the district exercises substantial control over both the respondent and the context in which the sexual harassment occurs. Title IX applies to all of a district’s education programs or activities, whether such programs or activities occur on-campus or off-campus.
Did the incident occur during a school program or activity involving a person in the United States?
□ Yes
□ No
To meet the definition of Title IX sexual harassment, the conduct needs to satisfy one or more of the following (please check all that apply):
- A district employee conditioning the provision of an aid, benefit, or district service on an individual’s participation in unwelcome sexual conduct, commonly referred to as quid pro quo sexual harassment.
- Unwelcome conduct determined by a reasonable person to be so severe, pervasive and objectively offensive that it effectively denies a person equal access to a district education program or activity.
- Sexual assault, dating violence, domestic violence or stalking.
Dating violence means violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim and where the existence of such a relationship is determined by the following factors:
- Length of relationship.
- Type of relationship.
- Frequency of interaction between the persons involved in the relationship.
Domestic violence includes felony or misdemeanor crimes of violence committed by a current or former spouse or intimate partner of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabitated with the victim as a spouse or intimate partner, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction receiving federal funding, or by any other person against an adult or youth victim who is protected from that person’s acts under the domestic or family violence laws of the jurisdiction.
Sexual assault means a sexual offense under a state or federal law that is classified as a forcible or nonforcible sex offense under the uniform crime reporting system of the Federal Bureau of Investigation.
Stalking means stalking on the basis of sex, for example when the stalker desires to date a victim. Stalking means to engage in a course of conduct directed at a specific person that would cause a reasonable person to either:
- Fear for their safety or the safety of others.
- Suffer substantial emotional distress.
IX. Recommended Course of Action
After consultation with the complainant and consideration of the reported information, the Title IX Coordinator directs the report to proceed under the provisions of (check all that apply):
- No further action at this time (state the reason):
- Policy 2224 Nondiscrimination/Affirmative Action
- Policy 2224.1 Title IX Sexual Harassment Affecting
- Policy 4111.1/4211.1 Nondiscrimination/Affirmative Action
- Policy 5131.1 Harassment, Intimidation and Bullying
- Policy 6121 Nondiscrimination/Affirmative Action
- Policy 6142.4 Physical Education and Health (Dating Violence)
- Title IX Information to Complainant
What supportive measures were discussed with the complainant, and what were the complainant’s wishes with respect to supportive measures?
Upon designating a course of action under Title IX sexual harassment, the Title IX Coordinator will promptly:
-
- Explain to the complainant the process for filing a formal complaint.
- Inform the complainant of the continued availability of supportive measures with or without the filing of a formal complaint.
- The Title IX Coordinator shall contact a student complainant’s parents/guardians and provide them with information regarding the report and Title IX sexual harassment procedures and grievance process for formal complaints, in accordance with applicable law.
The Title IX coordinator shall contact the emancipated or adult student and provide them with information regarding the report and Title IX sexual harassment procedures and grievance process for formal complaints, in accordance with applicable law
If the complainant/reporter, school staff or others with professional knowledge relating to the complainant’s health and well-being indicate that notifying the parents/guardians could cause serious harm to the health or well-being of the complainant or other person(s), the Title IX Coordinator will determine, in consultation with such individuals and upon advice of legal counsel, whether to withhold or delay notification of the report from the complainant’s parents/guardians.
-
- Determine what supportive measures may be offered to the respondent.
- Determine whether the complainant wishes this report to be treated as a formal complaint.
XI. Title IX Coordinator Signature
I recommend the above course of action based on my consultation with the complainant and the information available at this time.
Title IX Coordinator
Date:
XII. Title IX Formal Complaint Action
The Title IX Coordinator shall have the complainant check the appropriate box and sign and date below to indicate whether or not the complainant wishes to have this form serve as a formal complaint pursuant to Title IX.
I would like my report to be treated as a formal complaint pursuant to Title IX.
□ Yes □ No
Complainant’s Signature:
Date:
If the complainant does not wish this report to be treated as a formal complaint pursuant to Title IX, the Title IX Coordinator is also authorized to initiate this process despite a complainant’s wishes when actions limited to supportive measures are not a sufficient response to alleged behavior, or when a formal complaint process is necessary to investigate and address the situation adequately. For example, if the respondent is an employee, or if further investigation is needed to assess the extent of the behavior and impact on others, it may be reasonable to initiate the formal complaint process. The Title IX Coordinator may consult with the school attorney and other district officials in making this decision.
As Title IX Coordinator, I have determined that, notwithstanding the complainant’s preference, it is necessary to proceed with the Grievance Process for Formal Complaints for the following reasons:
Therefore, I am signing this form for the purpose of serving as the formal complaint initiating that process:
Title IX Coordinator’s Signature:
Date:
Based on the Pennsylvania School Boards Association report form: 103-Attach 1 Report Form