Student Conduct Form
Staff, students, and families are encouraged to report all concerns that might constitute a violation of the District's policy on Hazing, Harassment, or Bullying (HHB) or Title IX Sexual Harassment through this form. All information will be routed to the appropriate Building Administrator / Designated Employee or WNESU Title IX Coordinator for timely follow up.
Reporter Name:
*
First Name
Last Name
Reporter's Email:
example@example.com
School:
*
Please Select
Bellows Falls Middle School
Central Elementary School
Early Education Center
Grafton Elementary School
Saxtons River Elementary School
Westminster Center School
Did you directly witness the incident you are reporting:
Please Select
Yes
No
If you did not directly witness the incident please name witnesses here, if any known:
Identity of alleged student and / or staff offender(s) (if known):
Identity of complainant(s) (person or people targeted by the behavior):
Date and Time the alleged incident (if known):
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date report of harm shared with reporter:
-
Month
-
Day
Year
Date
Time report of harm shared with reporter:
Hour Minutes
AM
PM
AM/PM Option
Please describe the witnessed or reported conduct of concern (or attach summary of concerns below):
Do you have any other information about the alleged conduct, separate from what you outlined above? If yes, please outline here:
Please describe any initial actions you have taken to address the alleged conduct (notified police and / or DCF, etc.):
New August 2020: Any alleged conduct that may constitute sexual harassment under Title IX must be reported to the District's Title IX Coordinator. If you believe the alleged conduct might violate the District's Title IX policy, please indicate that below to ensure a copy of your report is routed to the Title IX Coordinator's attention:
*
Yes, I believe the alleged conduct involves sexual harassment
No, I do not believe the alleged conduct involves sexual harassment
I am unsure if the alleged behavior involves sexual harassment
If you have any additional information (screenshots, statements, etc.) please upload and attach to this report:
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