Title IX Complaint Form: AC-E-3

Note: A formal complaint means a document filed by a complainant (or parent/guardian) or signed by the Title IX Coordinator alleging sexual harassment against a respondent and requesting that the recipient investigate the allegation of sexual harassment. At the time of filing a formal complaint, a complainant must be participating in or attempting to participate in the education program or activity of the recipient with which the formal complaint is filed. A formal complaint may be filed with the Title IX Coordinator in person, by mail, or by electronic mail, by using the contact information set forth in Policy Exhibit AC-E-1.

Date: _______________

Name of complainant: __________________________________

School: _____________________________________________

Address: ____________________________________________

Phone: __________________________

Name(s) of individual(s) allegedly engaging in prohibited conduct: ________________________________________________________________________________________________________

Date(s) alleged prohibited conduct occurred: ____________________________________________________

Location(s) alleged prohibit conduct occurred: ________________________________________________________________________________________________________

Summary of alleged unlawful discrimination or harassment: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________

Name(s) of witness(es) to alleged prohibited conduct: ____________________________________________________ ____________________________________________________

Signature of complainant

____________________________________________________

Date _____________________________________

Signature of person receiving complaint

____________________________________________________

Date _____________________________________

 

Adopted: July 13, 2020

Revised: August 15, 2020