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Rappahannock Community College’s Formal Complaint Form
Today’s date: ____________________ Responsible Employee_________________________________
Information Regarding the Complainant:
Name of the Complainant:_________________________________________________________________________
Complainant’s Phone Number and Email Address:_______________________________________________________
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 different from 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 Sexual Harassment:
Time and date of the alleged Sexual Harassment: _______________________________________________________
Location of the alleged Sexual Harassment: □ on campus: □ off campus:
Other parties who may have information regarding the allegation(s), with contact information, if known:
Please provide a brief description of the alleged Sexual Harassment:
Please include the following information in your description when known: the gender of the parties, the relationship
between the parties, whether the Respondent used force in the course of the alleged Sexual Harassment, and the
frequency (if applicable) of the alleged Sexual Harassment.
Please feel free to use the reverse side of this form or separate pages to continue your description, if necessary.
By signing this formal complaint form, I am requesting the College to investigate the above allegation(s).
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