Title IX Complaint Form

Name of Complainant Question is mandatory

Email Address Question is mandatory

Phone Number Question is mandatory

Student Grade: Question is mandatory

School/Department (Location): Question is mandatory

Nature of Grievance: Question is mandatory

Please describe in detail the action you believe may be sex discrimination, including complaints of sexual harassment or sexual violence, in violation of Title IX and identify with reasonable particularity any person(s) you believe may be responsible.

Where did the actions take place? Question is mandatory

When did the actions described above occur? Question is mandatory

Are there any witnesses to this matter? Question is mandatory

Yes

If yes, please identify the witnesses:

Did you discuss this matter with any of the witnesses identified in Item 5? Question is mandatory

Yes

If yes, please identify the person to whom you have spoken:

Date:

Method of communication:

Have you spoken to any administrator(s) or other school employee(s) about this matter? Question is mandatory

Yes

If yes, please identify the person to whom you have spoken:

Date:

Method of communication:

Please describe any outcomes or actions steps that were taken as a result of the discussion(s) with administrator(s) or other school employee(s) Question is mandatory

PLEASE ATTACH ANY STATEMENTS, NAMES OF WITNESSES, REPORTS, OR OTHER DOCUMENTS WHICH YOU FEEL ARE RELEVANT TO YOUR COMPLAINT.

Attach

I certify that the foregoing information is true and correct.

Type Full Name: Question is mandatory