MGSD Title IX Complaint Form

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Purpose: The purpose of the Title IX formal complaint process is to inform Mooresville Graded School District of allegations of sexual harassment, sexual violence, and sex discrimination in violation of Title IX of the Education Amendments of 1972 so that the District may take appropriate action.

Instructions: Individuals alleging Title IX sexual harassment and requesting a review are required to complete this form as soon as possible after the occurrence of the alleged harassment to allow proper action by the Title IX Coordinator.

Name of Complainant (First M. Last): *

Complainant's full home address (Street, City, Zip): *

Complainant's phone number: *

Complainant's email: *

School Complainant attends: *

Name of Respondent (alleged perpetrator):
*

Nature of Complaint: Please describe the action(s) you believe may be sexual harassment, including complaints of sexual violence, in violation of Title IX and identify with reasonable particularity any person(s) you believe may be responsible.
*

When did the actions described above occur?
*

YYYY

Where did the actions described above take place?
*

Are there witnesses to this matter?
*

Yes

If you answered yes to the above question, please name witnesses (If no, please put N/A): *

Did you discuss this matter with any of the witnesses identified above?
*

Yes

There were no witnesses identified.

If you discussed this matter with a witness, please give the name of the witness you discussed this matter with, the date of the discussion, and method of communication (If no, please put N/A): *

Have you spoken to any school or district administrator(s) or other MGSD staff members about this matter?
*

Yes

If you answered yes to the above question, please name the MGSD administrator or staff member, the date of the discussion, and method of communication (If no, please put N/A):
*

Please describe any additional sources of information that you feel are relevant to your complaint:
*

I understand that clicking "Submit" acts as my digital signature to this form. *

Yes

Required

Submit

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