Title IX Complaint Form
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Relationship to Ivy Street School of Person Filing Complaint:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Name of the person against whom the allegation is made:
Basis of alleged complaint (choose one or more as appropriate):
sex discrimination
sexual harassment
sexual assault
sexual violence
gender discrimination
Is this based on an alleged reataliation (e.g., filing an earlier complaint)?
Yes
No
Please describe below the alleged discriminatory, discriminatorily harassing and/or retaliatory acts:
Attach additional pages, as well as list of witnesses and any appropriate documents as necessary:
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I affirm that the above complaint with attached pages is true to the best of my knowledge, information and belief.
Yes
No
I understand that copy of this document may be disclosed to the person(s) against whom this complaint is made, to his or her representative and to appropriate administrative personnel.
Yes
No
I understand that, depending on the nature of my complaint, I may have the right to file this complaint with the Massachusetts Commission Against Discrimination, the U.S. Equal Employment Opportunity Commission, or the Office for Civil Rights and the U.S. Department of Education.
Yes
No
Signature
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