Policies » Section J: Students » JBAA-R: Sexual Harassment And Sexual Violence Report Form

Policy Date: 06/05/2021

HSD File: JBAA-R
HOOKSETT SCHOOL DISTRICT
SEXUAL HARASSMENT AND SEXUAL VIOLENCE
REPORT FORM

General Statement of Policy Prohibiting Sexual Harassment
The school district maintains a firm policy prohibiting all forms of discrimination based on sex. Sexual harassment and sexual violence against students or employees is sex discrimination. All persons are to be treated with respect and dignity. Sexual violence, sexual advances or other forms of personal harassment by any person, male or female, which create an intimidating, hostile or offensive environment will not be tolerated under any circumstances.

Complainant:

______________________________________________

Home Address:

____________________________________

____________________________________

Work Address:

____________________________________

____________________________________

Home Telephone:

__________________________

Work Telephone:

__________________________

Date of Alleged Incident(s):

__________________________

Name of person you believe sexually harassed or was sexually violent toward you:

________________________________________________

List any witnesses that were present:

_________________________

_________________________

_________________________

_________________________

Where did the incident(s) occur?:

_______________________________________________________________

_______________________________________________________________

Describe the incident(s) as clearly as possible, including such things as: what force, if any was used; any verbal statements (i.e., threats, requests, demands, etc.); what, if any, physical contact was involved; what did you do to avoid the situation, etc. (Attach additional pages if necessary):

_______________________________________________________________

_______________________________________________________________

This complaint is filed based on my honest belief that___________________________ has
sexually harassed or was sexually violent to me. I hereby certify that the information I have
provided in this complaint is true, correct, and complete to the best of my knowledge and belief.

Complainant’s Signature_____________________________ Date_____________________

Received by_______________________________ Date_______________________