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Title IX Formal Complaint
A complainant, their parent(s)/guardian(s) or the Title IX Coordinator may file a formal complaint of sexual discrimination including sexual harassment by filling out this form. A notification will be sent out the Title IX Coordinator, but CJM highly recommends reaching out to the Title IX Coordinator in person or via email after filling out the form.
The purpose of the formal complaint form is to request CJM to investigate allegations of sexual harassment.
If a student believes himself/herself to be in danger, please contact law enforcement and/or a trusted adult right away.
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Today's Date
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Complainants Name
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Your answer
Complainants Guardian/Parent(s) Name(s)
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Your answer
Complainants Phone Number
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Your answer
Complainants Contact Email
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Your answer
Name of Respondents(s)
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Your answer
Relationship of Complainant and Respondent
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Your answer
Date(s) and Time(s) of Incident(s)
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Your answer
Location of Incident(s)
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Your answer
Complaint – Describe in as much detail as possible the exact words or behaviors that are the subject of your complaint
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Your answer
Has this behavior happened before? If so, please indicate when:
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Your answer
Have you reported this problem to a teacher, principal, other school staff, or law enforcement before? If yes, to whom was it reported and what occurred in the past?
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Your answer
Is there anyone who witnessed the incident(s) and if so, please list their name(s):
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Your answer
Did you discuss this matter with any of the witnesses listed above? If yes, please identify who you spoke with, when, and the method of the communication.
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Your answer
Do you have any documentation, pictures, texts, etc., to support your complaint? If yes, please indicate what documents you have and deliver them to CJM's Title IX Coordinator.
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Your answer
How has the complained of behavior affected you?
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Your answer
What would you like Cypress Junction Montessori to do to help?
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Your answer
I certify that, to the best of my knowledge and belief, that the information provided by me on this form is “true and correct” and not a “false statement or charge” to the best of my knowledge. Providing false information may lead to discipline.
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