Title IX Discrimination Complaint Form

Title IX Complaint Form
Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681) is an all-encompassing federal law that prohibits discrimination based on the gender of students and employees of educational institutions which receive federal financial assistance. When the form has been completed and signed by you, and then signed by the Title IX Coordinator or a Deputy, your complaint has been properly received and noted by the college. We will provide you with a copy of this form as well as complete information about the Title IX complaint process.
I am filing this complaint as a
Name

First NameLast Name
Department (if applicable)
Work Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employee ID/Student ID
Have you brought this matter to the attention of any other department(s) at the college? If so, please list the name(s) and department(s) of all other persons with whom you have discussed this matter.
Type of Complaint (check all that apply)

BullyingCyber bullyingGender DiscriminationGender InequitySexual HarassmentSexual AssaultSexual MisconductStalkingRapeRetaliationRelationship Violence
Complaint: Describe your complaint.
Name of person or persons you believe committed the offense against you and how you have contact with them, e.g. supervisor, co-worker, faculty, customer.
Describe the corrective action you are seeking.
For retaliation complaints, please explain why you believe someone retaliated against you.
Witnesses (the relationship information requested means co-worker, supervisor, customer, faculty, etc.)
Witness #1
Name
Relationship
Phone Number

Area CodePhone Number
Witness #2
Name
Relationship
Phone Number

Area CodePhone Number
Witness #3
Name
Relationship
Phone Number

Area CodePhone Number
I certify the aforementioned is true and correct

Clear
Date

MonthDayYear
For the Title IX Coordinator and/or Designee Complaint taken by

Clear
Title IX Coordinator Name

First NameLast Name
Date

MonthDayYear
The Title IX Coordinator and/or Designee investigate complaints by faculty, staff, and students who believe themselves to be harmed by sexual harassment or discrimination and harassment related to gender.
Should be Empty:

Title IX Complaint Form

Witnesses (the relationship information requested means co-worker, supervisor, customer, faculty, etc.)