Electronic Title IX Complaint

Full Name*

Preferred Name

You are a:

Student

Staff

Non Student

If you are a student or a staff, please provide your M number:

Local Address*

Contact Phone No.*

Ethnicity

Sex

Male

Female

Other

Your Major

Incident Location*

Incident Date and Time*

List Staff and Authorities present:

This is a Title IX investigation (not legal). You have the right not to speak to the investigator regarding the incident, hoever, failure to do so can have a negative impact as your perspective will no be taken into account.

Your Statement (Describe the who, what, when, where, how):*

Are you aware of anyone else that saw/heard the incident?

Yes

No

Select if applied:

Check here if there are no changes to the original report filed with DPS and there is no further information to be shared with regard to this incident.

I understand that this statement will be used to investigate alleged violations of Title IX rules and regulations. I further understand that it is not guranteed confidential and may be reviewd by all parties involved during an investigation/appeal process. These records are protected by the Family Educational Rights and Privacy Act and are provided under an exception to the Act found in section 99.32. THese records must be maintained confidentially.

E-Signature*

Date*

Title IX Electronic Complaint