Fillable Title IX Discrimination Complaint Form (Full Sail University)

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Title IX Discrimination Complaint Form (Full Sail University)

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Title IX Discrimination Complaint Form
CONTACT:
Shayne Cade
Title IX Coordinator
Business Office, Full Sail University
3300 University Boulevard
Winter Park, FL 32792
scade@fullsail.com
407 679-0100
To file a complaint with the university, please complete and mail, email, or bring this form to the office listed above. Or, you
may call the number above to make arrangements to meet with the Title IX Coordinator. If you are unable for any reason to
complete this form and would like to make a verbal complaint, please call the contact listed above.
The university will use its best efforts to keep a complaint of discrimination confidential; however, the university has an
obligation to investigate the complaint and during the course of the investigation may disseminate information concerning
the complaint to those who have a need to know.
Please contact the Title IX Coordinator if you have any questions regarding the process for filing or investigating complaints
of discrimination.
A victim of discrimination or harassment is encouraged to use the university’s internal complaint process. Persons
believing they have been discriminated against or harassed may seek assistance from government agencies including the
Department of Labor, Department of Education, or Office of Civil Rights.
Title IX Discrimination Complaint Form
Title IX of the Educational Amendments of 1972 prohibits discrimination in education on the basis of sex.
For a full definition, please review the university’s published Title IX policies and procedures.
Full Sail University Affiliation (please check)
qFACULTY
qSTAFF
qSTUDENT
qEMPLOYMENT APPLICANT
qOTHER
IF OTHER, PLEASE EXPLAIN:
Complainant
LAST NAME FIRST NAME M.I.
ADDRESS
TELEPHONE EMAIL ADDRESS
Person Who Discriminated Against You:
NAME TITLE DEPARTMENT
Description of Complaint:
Describe your complaint and why you believe this person discriminated/ retaliated against you. Explain why you have
contact with this individual, e.g. supervisor, co-worker, faculty, etc. Give date(s), time(s), place(s) the discrimination/
retaliation occurred. Attach additional pages if necessary.
Nature of Complaint (please check)
qSEXUAL ORIENTATION
qGENDER/SEX
qSEXUAL HARASSMENT/VIOLENCE
qOTHER
IF OTHER, PLEASE EXPLAIN:
Previous Action:
Have you brought this matter to the attention of any other department(s) at the university? If so, please list the name(s)
and department(s) of all other persons with whom you have discussed this matter.
Complaint Documentation:
Explain any documentation supporting your complaint and, if possible, provide it to the Title IX Coordinator with this form.
Corrective Action Sought:
Describe the corrective action you are seeking.
Witnesses:
(Relationship=co-worker, supervisor, classmate, faculty, etc.)
NAME TITLE/RELATIONSHIP TELEPHONE
NAME TITLE/RELATIONSHIP TELEPHONE
NAME TITLE/RELATIONSHIP TELEPHONE
Declaration:
I declare under penalty of perjury that the information provided here is true and correct.
SIGNATURE PRINT NAME DATE
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Completed 16 August 2020

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