Title IX Complaint Form (TIXC-1)
The purpose of this Title IX complaint form is to gather the essential facts as to the alleged actions to allow for the prompt and equitable resolution to complaints based on sex discrimination or retaliation in violation of Title IX of the Education Amendments of 1972 (“Title IX”). This form applies only to complaints alleging sex discrimination prohibited by Title IX (including sex-based harassment).
Please fill out this form completely. If you need more space, use a separate sheet(s) of paper. The completed form should be submitted to one of the District’s Title IX Coordinators as soon as possible after the occurrence of the alleged discrimination.
Name of Complainant:
Date and Time Received: (for District use only)
Contact Information:
Name of Individual Receiving Complaint: (for District use only)
Student Grade, if applicable:
District Case No.: (for District use only)
School/Department (Location):
Nature of Complaint. Please describe in detail the action you believe may be sex discrimination, including complaints of sex-based harassment, in violation of Title IX, and identify with reasonable particularity any person(s) you believe may be responsible. Please attach additional sheets, if necessary.
Location(s) of Alleged Title IX Conduct. Please describe in detail the location(s) in which the conduct took place.
Date/Time of Conduct. Please describe when the conduct occurred.
Witnesses.
Identify by name, telephone number, and address all witnesses you believe have knowledge of the conduct described above. Provide a summary of the facts known by each witness.
Did you discuss this matter with any of the witnesses identified above? If yes, please identify with whom you have spoken, the date of such communication, and the method of communication.
Prior Reports. Have you spoken to any administrator(s) or other school employee(s) about this matter? If yes, please identify to whom you have spoken to, the date of such communication, the method of communication, and the outcome of such communication.
Documents. Please attach any statements, names of witnesses, reports, or other documents which you feel are relevant to your complaint.
Certification
I certify that the foregoing information is true and correct.
Signature Date
Printed Name
