Title IX Reporting- Sexual Harrassment Reporting Form

ACA complies with federal and state laws prohibiting unlawful discrimination based on race, color, national origin, sex, disability and age in its programs and activities. Any person that believes they have been harassed or discriminated against based on his/her sex can file a complain under this procedure by filling out this form that goes to our Title IX Coordinators as follows: Student Coordinator: Heather Henderson Staff Coordinator: Melissa Holdaway

Complainant First Name*

Complainant Last Name*

Residential Address*

Best Contact Phone Number*

Respondent Name*

Person whom complaint is against

Describe the alleged sexual harrassment in specific terms.*

Include: 1. The specific incident or activity that is alleged to be in violation of Title IX 2. The name of all individuals involved. 3. Dates, times and locations involved

Describe any relevant communication that has already occurred to address this issue. Please specify the types of communication, dates, names of individuals with whom any communication has occurred.*

Is there any other relevant information you would like to share about this issue?*

Do you want this complaint to be formally investigated and addressed by the school?*

Yes

Electronic Signature of Complainant*

Accessibility

If you use assistive technology and the format of any material on this form interferes with your ability to access information, please contact the ACA Tech Desk at acatechdesk@azcharter.com or by calling 623-974-4959. To enable us to respond in a manner most helpful to you, please indicate the nature of your accessibility need, the preferred format in which to receive the material and your contact information.

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