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Harassment, Discrimination (Including Sexual Misconduct) and Retaliation On-Line (Texas A&M University - Kingsville)

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OFFICE OF COMPLIANCE/ TITLE IX
MSC 221 · KINGSVILLE, TEXAS 78363-8202
PHONE (361) 593-4758 · EMAIL TITLEIX@TAMUK.EDU
Harassment, Discrimination (Including Sexual Misconduct) and Retaliation
On-Line Complaint Form
Prior to submitting a complaint, please review the Texas A&M University System Regulation 08.01.01,
Civil Rights Compliance, and the Texas A&M University—Kingsville Rule 08.01.01.K1, Civil Rights
Compliance.
This form is designed to provide Texas A&M University—Kingsville students, staff, faculty, vendors,
visitors, or others with an on-line method to report specific information related to an alleged incident(s)
of discrimination, harassment (including sexual misconduct), or retaliation.
Please note that this form is not intended for use as an anonymous reporting option. If you would like to
report anonymously, please click the following link and leave the reporters information blank:
https://secure.ethicspoint.com/domain/media/en/gui/20501/index.html
You are not required to complete the entire form in order for the complaint to be submitted. The
University will use the information provided to begin an inquiry/investigation, which may include
contacting the complainant, respondent, and/or any potential witnesses. However, if the report does not
contain specific information, the University’s investigation and response may be limited.
Complainant Information*:
Are you a:
Student
Staff
Faculty
Vendor
Visitor
Other
If other, please specify: ________________________________________________________________
If you wish to identify yourself, please fill in the information listed below:
Last Name: ___________________________ First Name: _______________________ MI: ________
Address: ____________________________________________________________________________
City: ________________________________ State: __________________________ Zip: __________
Contact Number: ______________________ Email: ________________________________________
*If the person completing this form is the victim, you may choose to identify yourself or not. If you are a
third party complainant who is not the victim, include the victim’s identifiable information only if the
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victim wishes.
*Victims completing this form who provide personally identifiable information should expect the
university to follow-up with an appropriate review. For information-only reports, victims should omit all
personally identifiable information to ensure confidentiality.
Type and Basis of Complaint:
Type of Complaint:
Discrimination*
Harassment*
(including sexual misconduct)
Retaliation
*If you are filing a discrimination or harassment complaint, please indicate the protected status(es) that
is/are the basis of the alleged behavior:
Race
Color
Sex
Sexual Orientation
Gender Identity
National Origin
Age (DOB:______)
Genetic Information
Religion
Veteran Status
Disability
Respondent/Accused Information*:
Please identify the person against whom your complaint is made.
Name: ______________________________________________________________________________
Contact information:
Is this person a:
Student
Staff
Faculty
Vendor
Visitor
Other
If other, please specify: ________________________________________________________________
Title/Department (if applicable): _________________________________________________________
Relationship/Association to you: _________________________________________________________
Additional Respondent Information:
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*If the person completing this form is the victim, you may choose to identify yourself or not. If you are a
third party complainant who is not the victim, include the victim’s identifiable information only if the
victim wishes.
*Victims completing this form who provide personally identifiable information should expect the
university to follow-up with an appropriate review. For information-only reports, victims should omit all
personally identifiable information to ensure confidentiality.
Complaint:
While providing details is essential to investigating your complaint, please be advised that some or all of
the information you provide in this section may be shared with the person(s) you are accusing. You may
supplement this description if you wish to share additional details at a later time.
1. Describe the incident(s)/events(s) including dates, times, location, and any potential witnesses to
the behavior:
2. Describe the impact that the behavior has had on you:
3. Have you taken any action to stop the behavior? Yes No
If so, what actions have you taken and what was the outcome?
4. Please provide any additional information that supports your complaint?
Resolution:
What remedy are you seeking?
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By submitting this form I certify that the information I have provided is true and accurate to the
best of my knowledge.
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Harassment, Discrimination (Including Sexual Misconduct) and Retaliation On-Line (Texas A&M University - Kingsville)

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Completed 24 July 2020

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