Fillable Title IX COMPLAINT FORM (Richland Community College)

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Title IX COMPLAINT FORM (Richland Community College)

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Title IX COMPLAINT FORM
For additional information or questions, please contact:
Alex Berry, Title IX Coordinator
N105 (Student Success Center)
aberry@richland.edu | 217.875.7211 ext. 6314
Instructions: This report should be submitted to the College’s Title IX Coordinator, Alex Berry (N105), who will
forward it to the proper office for appropriate action.
You may submit the form in person or via email at aberry@richland.edu.
As a survivor, you have the right to report or not report an incident. Filing a Title IX complaint serves as official
notice to Richland Community College and authorizes the Title IX Coordinator to initiate a preliminary
investigation into the information and allegations contained within the report.
INFORMATION REGARDING THE COMPLAINANT (Person filing the complaint)
Complainants Name: _________________________________________________________________
College Status: Student Faculty Staff Not with the College
Complainants email: __________________________________________________________________
Complainants telephone number: _______________________________________________________
INFORMATION REGARDING THE ALLEGED VICTIM (if not the complainant)
Name of the Victim: __________________________________________________________________
College Status: Student Faculty Staff Not with the College
Victims email: ________________________________________________________________________
Victims telephone number: ______________________________________________________________
INFORMATION REGARDING THE RESPONDENT (Person(s) the complaint is about)
Respondents Name: ____________________________________________________________________
College Status: Student Faculty Staff Not with the College
Respondents email (if known): ____________________________________________________________
Respondent’s telephone # (if known): ______________________________________________________
TYPE OF COMPLAINT (Select all that apply)
Sex Discrimination  Sexual Assault Sexual Harassment  Sexual Violence Retaliation  Stalking
INCIDENT INFORMATION
Date and time alleged incident occurred: ____________________________________________________
Title IX COMPLAINT FORM
Revised February 2018
For additional information or questions, please contact:
Alex Berry, Title IX Coordinator
N105 (Student Success Center)
aberry@richland.edu | 217.875.7211 ext. 6314
Location of the alleged incident: Kn ampus Kff ampus
Specific Location (Room/Address)͗ ___________________________________________________________
t/dE^^/E&KZDd/KE
Please list any witnesses who may have information regarding the alleged incident, along with email address and/or
phone number if known:
__________________________________________________________________________________________________
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yW>Ed/KEK&/E/Ed(Please provide as much information as possible including but not limited to: nature of the
misconduct, gender of the parties, relationship between the parties, frequency of the misconduct, whether one or more
of the parties were under the influence of alcohol or drugs at the time of the alleged misconduct, impact the conduct
had on the complainant’s well-being. Attach additional pages and relevant documents.)
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I certify that the information I have provided on this Complaint Form is true and accurate to the best of my knowledge.
____________________________________ ____________________________________
Submitted by (print name) Phone or email address
____________________________________ ____________________________________
Signature Current Date
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Title IX COMPLAINT FORM (Richland Community College)

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Completed 25 July 2020

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