Arkansas Tech University Complaint Form
By submitting this form, I acknowledge that I am filing a formal complaint and have read and understand the Arkansas Tech
University Sexual Misconduct Policy. I also certify that the information given is true and complete to the best of my knowledge.
Name:
Date:
Phone Number:
Report submitted By:
Email:
Detailed Information:
Victim Information:
Employee Student Other
Define Other:
Name: Tech I.D. Number:
Address:
City, State, Zip:
Email:
Phone:
Name:
Respondent/Accused Information:
Employee Student Other
Define Other:
Address:
Tech I.D. Number:
Email:
Phone:City, State, Zip:
Witness Information:
Employee Student Other
Name:
Phone:
Email:
(Completion of every field is not required, but please provide as much information as possible)
Employee Student Other
Name:
Phone:
Email:
Employee Student Other
Name:
Phone:
Email:
Employee Student Other
Email:
Phone:
Name:
(additional witness information may be provided at a later date)
Define Other:
Interim Requests: (During the investigation and prior to the determination of a policy violation, you may request a temporary remedy)
No Contact Order Relocation ( work/residence hall ) Schedule Change (class/work shift) Other
Define Other:
On the following page please provide detailed information regarding the events that occurred. Remember to include
important details, such as, dates and times of all incidents, locations, witnesses present, etc. Please attach additional
pages if you would like to provide more information than the space will allow.
(If there is more than one respondent, please check other. In the Define Other box please put "multiple" and list
all individuals in the box provided on the following page.)
Define Other: Define Other:
Define Other: Define Other:
