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:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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