Title IX Notification Form

Title IX Notification Form
Purpose: The purpose of the Title IX formal process is to inform the District of allegations of sexual harassment, sexual violence and sex discrimination in violation of Title IX of the Education Amendments of 1972 (“Title IX”) so that the District may take appropriate action.
Instructions: Individuals alleging Title IX violations and requesting a review are required to complete this form and submit it to the Title IX Coordinator as soon as possible after the occurrence of the alleged harassment or discrimination..
StaffStudentAnonymous
StaffStudent
Complainant Information
Name*
School/Office*
Phone*
Format: (000) 000-0000.
Address*
Incident Information
Name of person(s) you believe committed an offense*
Case Type*
Sub Case Type*
Location of Incident*
Date of Incident*

MonthDayYear
Date
YesNo
Incident Details*
YesNo
List name(s) of any known witnesses*
Acknowledgement
I certify the aforementioned is true and correct.
Name*

First NameLast Name
Position/Title*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Complainant Information