TITLE IX and SaVE COMPLAINT FORM
You do not have to use this form to file a Title IX or SaVE complaint with
Wilson Community College. You may send a letter or e-mail instead of this form, but the letter or e-mail must include the
information requested below. The Title IX Coordinator can also complete this form with a complainant in a face-to-face
meeting. If additional space is required, please attach added pages. Please attach any documentation that would assist the
investigation.
1. Name of person filing this complaint:
Last Name: _______________ First Name: ________________ Middle Name: ____________
Address: _______________________________________________________________________
City: __________________________ State: ________ Zip Code: ______________
Home Telephone: _________________ Work / Cellular Telephone: _____________________
E-mail Address: _________________________________________________________________
2. Complainant - Name of person discriminated against (if other than person filing). If the person discriminated against is
age 18 or older, we need that person’s signature on this form stating that the information provided is true and
accurate. If the person discriminated against is a minor, the signature of the minor’s parent or legal guardian is
required.
Last Name: __________________ First Name: ____________ Middle Name: ______________
Address: _______________________________________________________________________
City: ______________________ State: ________________ Zip Code: ____________________
Home Telephone: ___________________ Work/Cellular Telephone: _____________________
E-mail Address: _________________________________________________________________
3. Under Title IX, the College is required to investigate all complaints of sexual / gender discrimination, harassment, or
violence that is severe, persistent, or pervasive sufficient to deny or limit the participation of any individual in any
College service, program, or activity. Under SaVE, the College is required to investigate domestic violence, dating
violence, sexual violence, and stalking when the alleged discrimination took place on our campus or limits or denies an
individual’s ability to participate in a College service, program, or activity, when the alleged discrimination took place
on an off-campus, College approved activity, or when both parties are directly connected to the College.
Please indicate the basis of your complaint:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
____________________________________________________________________________________
4. Respondent - Name(s) of the person(s) who allegedly discriminated against you:
________________________________________________________________________________________________
________________________________________________________________________________________________
__________________________________________
Is this person(s) a student at the College? ________ An employee at the College? ___________
A visitor to the College? ______________ Other? _____________________________________
Please describe this person(s)’s connection to the College, if known.
________________________________________________________________________________________________
________________________________________________________________________________________________
__________________________________________
5. Please describe each alleged discriminatory act. For each action, please include the date(s) the discriminatory act
occurred, the name(s) of each person(s) involved and why you believe the discrimination was because of sex or
gender. Also please provide the name(s) of any person(s) who was present and witnessed the act(s) of discrimination.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
____________________________________
6. What is the most recent date you were discriminated against?
______________________________________________________________________________
7. Have you attempted to resolve these allegations with the Respondent? ____________________
If so, how?
________________________________________________________________________________________________
________________________________________________________________________________________________
__________________________________________
8. Have you reported the discriminatory action to anyone else?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________
9. If the allegations contained in this complaint have been filed with any other federal, state, or local civil rights agency,
or any federal or state court, or federal, state, or local law enforcement authority, please give details and dates. The
College will determine whether it is appropriate to contact any other agency regarding your complaint.
Agency or Court: ________________________________________________________________
Law Enforcement Authority: _______________________________________________________
Date Filed: _____________________
Case Number or Reference: _______________________________________________________
Results of Investigation / Findings by Agency, Court, or Law Enforcement Authority:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________
10. If we cannot reach you at home or work, we would like to have the name and telephone number of another person
(relative or friend) who knows where and when we can reach you. This information is not required, but it could be
helpful in our investigation.
Last Name: ___________________ First Name: _____________________ Middle Initial: ____
Home Telephone: ____________________ Work/ Cellular Telephone: ____________________
E-mail Address: _________________________________________________________________
11: What would you like the College to do as a result of your complaint what remedy are you
seeking?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
____________________________________________________________________________________
With my signature, I declare that the information contained in this Complaint Report is true and correct to the best of
my knowledge. I further declare that it is true and correct that I am the person named below; and, if the complaint is
filed on behalf of a minor child / ward, that I am that person’s parent or legal guardian. If this complaint was filed on
behalf of a specific person who is younger than 18 years old or a legally incompetent adult, this form must be signed
by the parent or legal guardian of that person.
________ ___________________________________________________________
Date: Signature - Complaint filed by / Number 1 Above:
________ ___________________________________________________________
Date: Signature Complainant / Number 2 Above:
Please sign section A or section B below (but not both):
A. I give my consent to reveal my identity (and that of my minor child / ward on whose behalf the complaint is filed)
to others to further the College’s investigation and enforcement activities.
________ ___________________________________________________________
Date Signature
OR
B. I do not give my consent to reveal my identity (and that of my minor child / ward on whose behalf the complaint is
filed) to others to further the College’s investigation and enforcement activities. I understand that the College’s
investigative and enforcement activities may be limited by not being able to reveal my identity.
________ ___________________________________________________________
Date Signature
September 2014
Please use this area to expand on your answers or to give additional information.
Print
Reset