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Title IX Complain Form

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Title IX Discrimination Complaint Form

Title IX COMPLAINT FORM PURPOSE: The purpose of this Title IX grievance form is to gather the essential basic facts of the alleged actions in order that, prompt and equitable resolutions of complaints based on sex discrimination, including complaints of sexual harassment or sexual violence, in violation of Title IX of the Education Amendments of 1972 (“Title IX”) can be resolved as expediently and appropriately as possible.

INSTRUCTIONS: Individuals alleging Title IX discrimination and requesting review are required to complete this form and submit it to the appropriate administrator as soon as possible after the occurrence of the alleged discrimination:

1. Contact Information:
Name : __________________________________________________
Student Grade: ___________________________________________

2. Nature of Grievance:
Please describe the action you believe may be sex discrimination, including complaints of sexual harassment or sexual violence, in violation of Title IX and identify with reasonable particularity any person(s) you believe may be responsible. Please attach additional sheets, if necessary:

__________________________________________________________________________________

3. When did the actions described above occur?

__________________________________________________________________________________

4. Are there any witnesses to this matter? (Please circle one) Yes No

If yes, please identify the witnesses:

__________________________________________________________________________________

5. Did you discuss this matter with any of the witnesses identified in Item 4?
(Please circle one) Yes No

If yes, please identify:

Name of the person to whom you have spoken:________________________________________

Date:_________________

Method of communication: ________________________________________

6. Have you spoken to any administrator(s) or other school employee(s) about this matter? (Please circle one) Yes No

If yes, please identify:

Name of the person to whom you have spoken:_______________________________________

Date:_________________

Method of communication: ________________________________________

7. Please describe the result of the discussion(s) identified in Item 6:

__________________________________________________________________________________

PLEASE ATTACH ANY STATEMENTS, NAMES OF WITNESSES, REPORTS, OR OTHER DOCUMENTS WHICH YOU FEEL ARE RELEVANT TO YOUR COMPLAINT.

I certify that the foregoing information is true and correct.

Print Name: ______________________________________________
Signature: ______________________________________________
Date: ______________________________________________

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

Print Name: ______________________________________________
Signature: ______________________________________________
Date: ______________________________________________