TITLE IX COMPLAINT FORM

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Middletown Public Schools

Title IX Formal Complaint

This complaint form is for allegations of Title IX sexual harassment This form must be completed as fully possible, including documentary evidence, to enable the District to conduct a full and fair investigation under Title IX regulations and the District Title IX Policy and Protocol. This Formal complaint is not considered complete or filed unless signed by either the Complainant or the Title IX Coordinator and it has been received by the Title IX Coordinator’s office. The District will initiate a full Title IX investigation only upon the Title IX Coordinator’s office receipt of a completed and signed Formal Complaint.

Sexual Harassment (Title IX):

Title IX protects people from discrimination based on sex in educational programs or activities that receive financial assistance. Under Title IX, discrimination based on sex can include sexual harassment, which is defined as conduct based on sex that satisfies one or more of the following:

Sexual harassment under Title IX means verbal, physical or other conduct that targets a person based on their sex, and that satisfies one or more of the following:

• A District employee conditioning educational benefits or services for participation in unwelcome sexual conduct (i.e., quid pro quo);

• Any unwelcome conduct that a reasonable person would find so severe, pervasive, and objectively offensive that it effectively denies a person equal access to any District or school education program or activity;

• Any instance of "Sexual assault" as defined in 20 U.S.C. 1092(f)(6)(A)(v), "dating violence" as defined in 34 U.S.C. 12291(a)(10), "domestic violence" as defined in 34 U.S.C. 12291(a)(8), or "stalking" as defined in 34 U.S.C. 12291(a)(30).

Reporting Sexual Harassment

Any person (whether or not they are the victim of the alleged conduct) may report suspected sexual harassment to any District staff member, including the Title IX Coordinator. Reports may be made in any manner, including in person, by email, by telephone or by mail, at any time, including during non-business hours. Title IX does not impose a time limit for reporting alleged incidents of discrimination based on sex, sexual harassment or retaliation; however, in order to ensure integrity, promote fairness, and facilitate an effective investigation, every effort should be made to report all instances of alleged sexual harassment or retaliation, as promptly as possible, and, if possible, not later than 180 calendar days after the alleged

conduct occurred.

Mandatory Reporting Guidelines

All non-student members of the School Community are required to report to the appropriate Title IX Coordinator any incident of sexual harassment or retaliation against any student that they witness, are notified of through a student's report or complaint, or that they otherwise become aware of, as soon as practicable, but no later than 24 hours after becoming aware of the incident.All reports must be made in writing and should include a completed "Title IX Formal Complaint Form" signed by the reporting party. No mandatory report under this section may be filed anonymously. Failure to comply with this mandatory reporting requirement or this Protocol may lead to disciplinary action.

For conduct involving both employees and students, or conduct involving third parties, reports may be made to:

Michelle Fonseca, Middletown Public Schools

Title IX Coordinator.

26 Oliphant Lane

Middletown, RI, 02852

(401) 849-2122

mfonseca@mpsri.net

The District shall respond promptly and meaningfully to reports of conduct that may constitute Title IX sexual harassment in a manner that is not "deliberately indifferent." The District shall investigate every formal complaint of sexual harassment and respond meaningfully to every known report of sexual harassment.

“The Middletown School Department does not discriminate on the basis of race, ethnicity, language, disability, religion, age ,gender, socio-economic status, sexual orientation, gender identity or expression, country of ancestral origin, interrupted education status, military status, genetic information (including family medical history), or any other category protected by law.”

Complainant FULL Name

Complainant District Address/Location

Complainant Home Address

Complainant Phone Number

Complainant Email

Date of Alleged Incident(s)

YYYY

Time of Alleged Incident(s)

Time

Name of person(s) you believe perpetrated the incident(s):

List any witnesses present:

Location of the incident(s)

Option 1

Clear selection

Describe the incident(s) as clearly as possible. Include any dates of alleged discrimination, identities of alleged perpetrators and specific circumstances of alleged discrimination including such things as: any verbal statements (i.e. threats, requests, demands, etc.); what (if any), physical contact was involved; what communication occurred (i.e. via text, email, social media, phone calls, etc.); or anything else related to this incident. Please provide any information you believe would be helpful in investigating this formal complaint.

By submitting this form I certify that the information I have provided in this formal complaint is true, correct, and complete to the best of my knowledge and belief. Further, by signing below, I acknowledge that I have an opportunity to receive reasonable supportive measures while this formal complaint and the allegations therein are investigated.

Person submitting the form is: (your name)

Submit

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