Title IX Formal Complaint Form
Please complete the below information to the best of your knowledge. Once it is complete, submit the form to the Office of Title
IX Initiatives in person at Cyert Hall, Suite 140, by email to TIX@cmu.edu, or mail to Title IX Coordinator, 5000 Forbes Ave., Cyert
Hall, Suite 140, Pittsburgh, PA 15213.
Complainant Name
Andrew ID: _____________
Contact Information:
Local address: ____________________________________________________________________________
Phone: ____________________________________ Preferred email: ________________________________
CMU Affiliation: Undergraduate Student (specify year)
Graduate Student (specify master’s or PhD)
Faculty Staff Alumna/Alumnus Unknown Applicant
Not Affiliated Other (specify)
Department/School
Nature of Incident(s) (check all that apply)
Sexual Assault (includes but not limited to: rape, sodomy, sexual assault with an object, fondling, incest,
statutory rape)
Sexual Exploitation Stalking Retaliation Violation of Protective Measures Dating Violence
Domestic Violence Sexual Harassment Undisclosed Other____________ I’m not sure
Date of Incident or is this concern ongoing? Date of First Incident
Location of Incident(s) (Check all that apply)
On‐Campus Property On‐Campus Residential Facility Off‐Campus Academic or
Public Property CMU Branch Campus Administrative Building
Other Pittsburgh Location Outside of Pittsburgh Unknown or Unreported Location
Brief Description of Misconduct:
