This form is for use by any member of the campus community (students, employees, and guests) to
submit an initial report of a campus incident or complaint. Once submitted, the report will be
reviewed by the Director of Student Support Services for followup regarding next steps, including
the possible involvement of additional members of the administration.
Every effort will be made to keep your personal information confidential, to the extent possible
depending on the specific incident, complaint or situation. If you choose to submit this report
anonymously, please be aware that it may limit the ability for thorough followup. Once complete,
please submit form to the Reception Desk in Founders Hall.
Type of Complaint (check all that apply):
Academic: issue/concern with a faculty member regarding his/her approach or interactions with
students in the classroom; unfair or inconsistent grading; or unprofessional behavior.
Behavioral/Personal Conflict: issue with another student, staff or faculty member on campus related to
(non-sexual) harassment or bullying, intimidating or threatening behavior.
Title IX (gender discrimination, sexual misconduct/harassment): issue with another individual related to
sexual misconduct or assault; discrimination or harassment that is gender-related; stalking; or retaliation
related to the reporting of any of the above.*
Other (please describe):
Date of incident:
Approximate time of incident:
am pm
In the case of Academic or Behavioral/Personal Conflicts, you must first try to address the issue
directly with the individual in question (this may include utilizing a mediator at your discretion).
*Sexual misconduct incidents are NOT expected to be addressed directly. In those cases, please
submit a complaint form as soon as you are able, in order to have the issue addressed formally.
If you checked any boxes other than Title IX, have you attempted to resolve the issue with the other
Date of attempt:
Approximate time of attempt:
am pm
No if you have not yet attempted to resolve your issue directly, you must do so first before submitting a
Description of Incident/Complaint
Please provide as much detail as possible, including date, times, location, names of involved individuals, etc. If needed,
attach any relevant supporting documentation and/or use additional space beyond what is provided below.
Remedy Requested (indicate the actions that you believe would resolve your complaint):
You may submit this form anonymously; however, if you wish to be contacted for followup and/or support, please
provide your contact information below.
Name: KCC ID#:
Email Address: Phone:
I have submitted what I believe are true statements as part of this complaint.
Signature Date
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