5145.44 Form 1

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)  ____________________________________

________________________________________________________________________

Location where such sexual harassment occurred          ______________________________

________________________________________________________________________

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: ______________________________