EPS Title IX/Sexual Harassment Complaint Form

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PURPOSE: Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681) prohibits discrimination based on the sex of students and employees of educational institutions which receive federal financial assistance. This form should only be used for complaints alleging sex discrimination prohibited by Title IX (including sexual harassment and sexual violence). If you require emergency assistance, please contact the appropriate school administrator. The District's Title IX Coordinator will contact you once you submit this Complaint Form. INSTRUCTIONS: Individuals alleging Title IX discrimination and requesting review are requested to complete and submit the below form as soon as possible. You may also fill out and submit to a District official the "Discrimination/Sexual Harassment/Bullying/Hazing/Dating Violence/Retaliation Report Form," which is Attachment 1 to Board Policy 103, Discrimination/Title IX Sexual Harassment Affecting Students https://www.eriesd.org/cms/lib/PA01001942/Centricity/Domain/576/103%20Attach%201.pdf.

If you have any questions, please contact your school administration or Susan Majocka Title IX Coordinator at smajocka@eriesd.org or at 814-874-6078.

First and Last Name of individual completing this report *

Email Address *

Phone Number *

Date of the incident/s

YYYY

Time of the incident/s (if known)

Time

Location of the incident *

If the answer to the above question is "Other" - please describe the location of the incident/s.

Where did the incident occur (Choose all that apply)?

Bus Stop

Cell Phone

Class Room

Hallway

Building Exterier

Internet

Ocker Room

Lunch Room

Parking lot

On the way to or from school

Restroom

Off Site Program

Off Site School Sponsored Function

School Bus

At a school sponsored activity or event off school property

Other

If "Other" - please explain

Type of Complaint?

Complainant (Full Name, school and Grade) - Individual who is alleged to be the victim of conduct that could constitute sexual harassment. *

Phone number of the Complainant

Respondent (Full Name, School, and Grade) - an individual who has been reported to be the perpetrator of conduct that could constitute sexual harassment.

Phone number for Respondent, if known

Witnesses - Please list full names of any witnesses and contact information if available.

Nature of Complaint:

Describe the behavior in detail in narrative form. Include full names of complainant, respondent and witnesses if known.

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