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Run: Title IX Sex Discrimination Complaint Intake and Formal Complaint Form

This Title IX Sex Discrimination Complaint Intake and Formal Complaint Form captures the facts, people, and evidence needed to start a K-12 grievance and sup...

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Submission Notice

What are you submitting? (required)

I understand this form may be shared with the Title IX Coordinator and relevant personnel for review, supportive measures, and grievance processing. (required)

Yes No N/A

I understand confidentiality cannot be guaranteed, but information will be handled as discreetly as possible and shared only on a need-to-know basis. (required)

Yes No N/A

Preferred contact method

Preferred contact details

Reporting Party Information

Your name

Optional if anonymous reporting is permitted by your organization.

Your role (required)

Your email address

Your phone number

Relationship to the affected party

Affected Party Information

Name of the student or employee affected

Affected party role (required)

Grade level or department

May the school contact the affected party directly? (required)

Are there immediate safety or access concerns that require urgent supportive measures?

Yes No N/A

Respondent Information

Is the respondent known? (required)

Respondent name

Respondent role

School, grade, team, or department

Incident Details

Date of incident

Location of incident

Type of concern (required)

Describe what happened (required)

Include only the facts you know, such as who, what, when, and where.

Has this happened more than once or appear to be part of a pattern?

Has this been reported before?

Supportive Measures and Immediate Needs

Requested supportive measures

Other supportive measures requested

Is there an urgent medical or safety need right now?

Immediate action requested

Describe any immediate steps you want the school to consider.

Witnesses and Evidence

Witness names or roles

Evidence available

Upload supporting evidence

Additional information

Formal Complaint Attestation

I am requesting that the school initiate the formal grievance process based on the information provided. (required)

Yes No N/A

I certify that the information provided is true and accurate to the best of my knowledge. (required)

Yes No N/A

Typed name (required)

Date (required)

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Email (required)

Your name (optional)

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