Using the Complaint Form
This complaint form may be used by complainants and persons filing the complaint on behalf of
complainants, Title IX Coordinators, and responsible employees.
Responsible employees and Title IX
Coordinators should get relevant facts, but they should not conduct an investigation (unless, of course, the
responsible employee is also an investigator of misconduct). All complaints must be forwarded to the Title
IX Coordinator immediately.
Appendix A
Complaint Form
Today’s date: ____________________ Responsible Employee: ______________________
Information Regarding the Complainant:
Name of the Complainant: _____________________________________________________________________________
Complainant’s Phone Number: _________________________________________________________________________
The Complainant is (please check one): □ faculty □ student □ staff □ not affiliated with the College
For faculty, staff, & students, indicate whether □ current or □ former
Information Regarding the Alleged Victim (if he or she is not the Complainant):
Name of the alleged victim: ___________________________________________________________________________
The alleged victim is (please check one): □ faculty □ student □ staff □ not affiliated with the College
For faculty, staff, & students, indicate whether □ current or □ former
Information Regarding the Respondent:
Name of the Respondent: ______________________________________________________________________________
Respondent’s phone number (if known):__________________________________________________________________
The Respondent is (please check one): □ faculty □ student □ staff □ not affiliated with the College
For faculty, staff, & students, indicate whether □ current or □ former
Information Regarding the Alleged Misconduct (sexual harassment, sexual violence, domestic violence, dating
violence, or stalking):
Time and date of the alleged Misconduct: ____________________________________________________________
Location of the alleged Misconduct: □ on campus: ______________________________________________________
□ off campus: _____________________________________________________
Witnesses or other parties who may have information regarding the alleged Misconduct, along with phone number,
if known:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Please provide a brief description of the alleged Misconduct:
Please include the following information in your description when known: the gender of the parties, the relationship between the
parties, whether one or more of the parties were under the influence of alcohol or drugs at the time of the alleged Misconduct, whether
the Respondent used force (physical or otherwise) in the course of the alleged Misconduct, and the frequency (if applicable) of the
alleged Misconduct.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
