Title IX Policy Violation Formal Complaint Form

Today's Date *

Name of Complainant *

Contact Information of Complainant (Phone number AND email) *

Complainant's Status *

Name of Respondent (the individually who allegedly engaged in Prohibited Conduct outlined in the Title IX policy): *

Respondent Status *

Date / Time of Incident: *

Date

Time

Location(s) of Incident: *

Name and Contact information of Any Witnesses (and their status as either student, faculty, staff, visitor or unknown) *

Description of Incident: *

Administrators notified, if any (Check all that apply):

Administrator (e.g. Dean of Students, etc)
Health Services (please note that these individuals are confidential resources and are not “responsible employees” of manor as prescribed in the Sexual Misconduct Policy (aka Title IX policy))
Counseling Services (please note that these individuals are confidential resources and are not “responsible employees” of manor as prescribed in the Sexual Misconduct Policy (aka Title IX policy))
Public Safety
Title IX Coordinator
Campus Chaplain (including student chaplains)
Faculty

Police called: *

Yes
No

Emergency Services called: *

Yes
No

If yes to either police or emergency services called, please provide the Officer’s Name and Badge number/ or the emergency services contact information.

Electronic signature and date: *

Terms of Acceptance and signature: I, the reporter of this form, warrant the truthfulness of the information provided above. I understand that checking the box constitutes a legal signature confirming that I acknowledged and agree to the Terms of Acceptance. *

Acceptance

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Student LifeTitle IX Information

Title IX Policy Violation Formal Complaint Form

Sexual Misconduct, Sexual Harassment, Sexual Exploitation, Stalking, Dating Violence, and Domestic Violence Formal Complaint Form