Title IX Concern Reporting Form
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TITLE IX CONCERN REPORTING FORM
REPORTER INFORMATION
Are you reporting anonymously? (Required)
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required
YES
NO
Name
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required
First Name
Last Name
YOUR ROLE
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Student
Parent / Guardian
Employee / Staff
Community Member
Other
Email Address
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Phone Number
PERSON AFFECTED
Single Choice
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Myself
Another Student
Another Individual
NAME OF PERSON AFFECTED
GRADE LEVEL
K-2
3-5
6-8
9-12
Not applicable
INCIDENT DETAILS
TYPE OF CONCERN
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required
Please select up to 9 choices
Sexual harassment
Sexual Assault
Dating Violence
Domestic Violence
Stalking
Sex-based discrimination
Pregnancy related discrimination
Retaliation
Other
Please select up to 9 choices
DATE OF INCIDENT
Must contain a date in MM/DD/YYYY format
TIME OF INCIDENT
LOCATION OF INCIDENT
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required
On Campus
School-sponsored activity
Online / digital
Off campus
Unknown
DETAILED DESCRIPTION OF INCIDENT
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Please include as much detail as possible, including names, actions, and any relevant context.
RESPONDENT (PERSON ACCUSED)
NAME OF PERSON(S) INVOLVED (IF KNOWN)
ROLE OF PERSON(S) INVOLVED
Student
Staff / Employee
Volunteer
Unknown
WITNESS & EVIDENCE
WERE THERE WITNESSES?
Yes
No
Unknown
WITNESS NAMES / CONTACT INFO
DO YOU HAVE ANY EVIDENCE?
Yes
No
Unknown
UPLOAD FILES
Attach up to 4 files with a maximum size of 10MB
Select File(s)
No file chosen
SAFETY & IMMEDIATE NEEDS
ARE YOU CURRENTLY SAFE?
Yes
No
Unknown
IF YOU ARE IN IMMEDIATE DANGER, PLEASE CALL 911 OR SEEK EMERGENCY ASSISTANCE.
WOULD YOU LIKE THE SCHOOL TO CONTACT YOU?
Yes
No
Not applicable (anonymous)
REQUESTED SUPPORT
Please select up to 3 choices
Counseling support
Schedule change
No-contact order
Academic accommodations
Other
Please select up to 3 choices
FORMAL COMPLAINT INTENT
DO YOU WANT TO FILE A FORMAL TITLE IX COMPLAINT?
Formal complaints trigger an investigation. The Coordinator will contact you to discuss.
Yes
No
Not sure
Formal complaints trigger an investigation. The Coordinator will contact you to discuss.
ACKNOWLEDGMENT STATEMENT
I understand that the information I am providing is accurate to the best of my knowledge and that submitting this form does not automatically initiate a formal complaint unless I indicate that intent.
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Acknowledgement
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