Title IX Complaint Form

Investigative Report of Alleged Harassment

Incident Reported To*

Incident Reported By*

Complainant's Name*

Complainant - Person making the complaint

Complainant's Designation*

Select

If Student, state age

If Other, please state.

School of the Complainant*

Select

Respondent's Name*

Respondent - Person responsible for the harassment

Respondent's Designation*

Select

If the respondent is a student, please state age*

If the respondent's designation is "other", please explain*

School of Respondent*

Select

Name of any witnesses to the complaint*

Where did the harassment occcur?*

When did the harassment occur?*

Date Respondent was notified*

File Attachments - nature of the complaint*

Attach the nature of the COMPLAINT, and the nature of the RESPONSE including a detailed account of the activity in question. Include, as much detail as possible, an exact recitation of words used, offensive touching, and/or nature of harassing activity.

Drag and drop files here or

Respondent’s answer to the complaint*

Respondent agrees with the complaint as stated by Complainant

Respondent disagrees with the complaint as stated by Complainant

Has an informal process taken place to resolve this complaint?*

Yes

Describe the nature of the informal process

(ie. Parent/Student Conference)

Date informal process occurred

Corrective Action/Consequence/Resolution

(Provide attachment, if necessary)

Remedial Support Offered to Complainant*

(ie. Student Support Plan)

Remedial Support*

Parent/Guardian accepted remedial support

Parent/Guardian denied remedial support

Check here if complaint was moved to the formal process

Send me a copy of my responses

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