4000.1
4200.1
COMPLAINT FORM REGARDING SEXUAL HARASSMENT UNDER TITLE IX (PERSONNEL)
This complaint form should be used for complaints of sexual harassment as defined on page 1 of the Board’s Administrative Regulations regarding the Prohibition of Sex Discrimination and Sexual Harassment (Personnel)
Name of the complainant ________________________________________________
Date of the complaint ______________________________________________________
Date of the alleged sexual harassment ____________________________________
Name or names of the sexual harasser(s) ____________________________________
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Location where such sexual harassment occurred ______________________________
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Name(s) of any witness(es) to the sexual harassment ______________________________
________________________________________________________________________
Detailed statement of the circumstances constituting the alleged sexual harassment
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Remedy requested_________________________________________________________
Signature of Complainant or Title IX Coordinator: ______________________________