Fillable COMPLAINT/INTAKEFORM LamarStateCollegePortArthuriscommittedtopromptresolutionofcomplaintsinamannerconsistent withtheTexasState UniversitySystemSexualMisconductPolicy.Youdonothavetousethisformto receiv

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COMPLAINT/INTAKEFORM LamarStateCollegePortArthuriscommittedtopromptresolutionofcomplaintsinamannerconsistent withtheTexasState UniversitySystemSexualMisconductPolicy.Youdonothavetousethisformto receiveassistance;however,thisformwillbeusedsothatwecanbecertainthatallnecessarystepsfor aresolutionhavebeencompleted.ThisformistobeusedforreportingtotheTitleIXCoordinator. Pleasefeelfreetoattachadditionalsheetsofinformationifyoubelievetheyarenecessary.Inaddition, pleaseprovideanydocumentationinsupportofyourclaim. (Lamar State College)

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The COMPLAINT/INTAKEFORM LamarStateCollegePortArthuriscommittedtopromptresolutionofcomplaintsinamannerconsistent withtheTexasState UniversitySystemSexualMisconductPolicy.Youdonothavetousethisformto receiv form is 4 pages long and contains:

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COMPLAINT/INTAKEFORM

LamarStateCollege‐PortArthuriscommittedtopromptresolutionofcomplaintsinamannerconsistent

withtheTexasState UniversitySystemSexualMisconductPolicy.Youdonothavetousethisformto

receiveassistance;however,thisformwillbeusedsothatwecanbecertainthatallnecessarystepsfor

aresolutionhavebeencompleted.ThisformistobeusedforreportingtotheTitleIXCoordinator.

Pleasefeelfreetoattachadditionalsheetsofinformationifyoubelievetheyarenecessary.Inaddition,

pleaseprovideanydocumentationinsupportofyourclaim.

PLEASEPRINTCLEARLY.

Ifyoubelieveyouhavebeensexuallyassaulted,harassed,ordiscriminatedagainstbyanymemberof

theLSC‐PAcommunityorwhileparticipatinginacollegesponsoredactivity,youareencouragedto

bringittotheattentionoftheTitleIXCoordinatorand/orotherCollegeofficial.

ThisformandanyattachmentscanbesubmittedtotheTitleIXCoordinator’sOfficelocatedinthe

Madison Monroe Building,Room208I.Pleaseallowaminimumof24hoursforreviewandforTitleIX

eligibilitydetermination.

Youmayalsoemailtheformtocooksl@lamarpa.edu (subjectline‐ComplaintForm).

Complainant(PersonFilingtheComplaint)

Name:________________________________________________________________________

Student:__________ Employee:__________Both:__________

Department:___________________________________________________________________

WorkPhone:_________________HomePhone:_________________CellPhone:_________________

Address:_____________________________________________________________________________

City,State,Zip:________________________________________________________________________

Emailaddress:________________________________________________________________________

Wheredoyouprefertobecontacted?Work_____________ Home_____________

NameofRespondent(IndividualComplaintIsAgainst)

Name:________________________________________________________________________

Student:__________ Employee:__________Both:__________

Department:___________________________________________________________________

WorkPhone:_________________HomePhone:_________________CellPhone:_________________

Address:_____________________________________________________________________________

City,State,Zip:________________________________________________________________________

Emailaddress:________________________________________________________________________

Wereyoudiscriminatedagainstwithregardtoyourrightsin:

Employment:______________Education:______________Retaliation:______________

Wereyoudiscriminatedagainstbecauseofyour:

Race:__________ Color:__________ NationalOrigin:__________

Religion:__________ Age:___________ Sex(Gender):___________

Disability:__________ VeteransStatus:__________ SexOrien

tation:__________

*SexualMisconduct:__________

*Ifyouhaveacomplaintregardingsexualmisconduct,pleasecompletethesectionbelow.

SEXUALMISCONDCUTQUESTIONAIRE‐whichofthefollowingtypeofsexualmisconductdoesyour

complaintfallunder?

a) SexualAssault  YESNO e) DomesticViolence  YESNO

b) SexualExploitation  YESNO f) DatingViolence  YESNO

c) SexualIntimidation  YESNO g) Stalking  YESNO

d) SexualHarassment  YESNO

Datefirstincidenttookplace:____________________________

Dateofmostrecentincident:____________________________

(Explain)

_____________________________________________________________________________________

_____________________________________________________________________________________

Endofsexualmisconductquestionnaire

Doyoucurrentlyfeelthatyouareatrisk?YESNO

Ifyes,pleaseexplain:

____________________________________________________________________________________

GeneralHarassment‐Ifyourcomplaintisnotcategorizedabove,itmaynotbeaformofdiscrimination

orsexualmisconduct.Whatisyourconcern?Pleaseprovidedocumentationinsupportofyourclai

mif

possible.

EXPLAIN:

____________________________________________________________________________________

Whohaveyoucontactedforhelpregardingthiscomplaint?

Name:____________________________________

Title:_____________________________________ Date:___________________________

Name:____________________________________

Title:_____________________________________ Date:___________________________

Name:____________________________________

Title:_____________________________________ Date:___________________________

Haveyounotifiedlawenforcementofficialsinregardstothisclaim?YESNO

Ifso,whichagency(s)andcontactperson?_________________________________________________

____________________________________________________________________________________

Whatistheactionstatuswiththeagency(s)involved?________________________________________

_____________________________________________________________________________________

Describetheinjuryorharmyousufferedbecauseoftheallegeddiscrimination.Pleaseattach

additionalsheetsifyouneedmoreadditionalspace.

____________________________________________________________________________________

____________________________________________________________________________________.

InformationtoIndividual

EveryoneatLamarStateCollege‐PortArthurhastherighttofileacomplaint.Theindividualcanfile

theircomplaintwiththefollowingoffices:

TitleIXCoordinator:Madison Monroe Education Building,Room208I

VicePresidentforStudentServices:StudentCenter,Room301

HumanResources:Business Office,Room122

AthleticDepartment:Carl ParkerCenter,Room102

StatementofEventsProvidedbyComplainant

Pleaseprovideadetailedstatementoftheevents,includingdates,places,andnamesofwitnesses.

Pleaseattachadditionalsheetsifyouneedmorespace.Also,provideanydocumentationinsupportof

yourclaim.

__________________________________________________________________________________

Whenconsideringreportingoptions,Victimsshouldbeawarethatcertainperso nnelemployedbyLamar

StateCollege‐PortArthurcanmaintainstrictconfidentiality,whileothershavemandatoryreportingand

responseobligations.LSC‐PApersonnelthatarenotconfidentialreportersandwhoreceiveareportof

allegedsexualmisconductarerequiredtoshare

theinformationwithappropriateadministrative

authoritiesforinvestigationandfollowup.LamarStateCollege‐PortArthurwillprotectaComplainant’s

confidentialitybyrefusingtodisclosehisorherinformationtoanyoneoutsidetheCollegetothe

maximumextentpermi ttedbylaw.AsforconfidentialityofinformationwithintheCollege,the

College

mustbalanceaVictim’srequestforconfidentialitywithitsresponsibilitytoprovideasafeandnon‐

discriminatoryenvironment.

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COMPLAINTINTAKEFORM LamarStateCollegePortArthuriscommittedtopromptresolutionofcomplaintsinamannerconsistent withtheTexasState UniversitySystemSexualMisconductPolicy.Youdonothavetousethisformto receiveassistance;however,thisformwillbeusedsothatwecanbecert

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Completed 30 July 2020

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