Policy Title IX Complaint Form - KGBSD School Board

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Title IX Complaint Form

E 0410.10

E0410.1 (e) Title IX Complaint Form

COMPLAINT of ALLEGED HARASSMENT, DISCRIMINATION, or BULLYING

FORM E

This form serves as a formal ﬁling of a Bullying, Harassment, Discrimination or Title IX Sexual Harassment complaint to Ketchikan School District. Please provide as much detail as possible when completing the information below. Return this form to your school administrator and to the Title IX Coordinator at TitleIX@k21schools.org

Today’s Date:		School/Department:
Incident Date		Time:		Location:

Name / Complainant:		Grade or Role:
Phone Number:		Email:
Home Address:

I wish to ﬁle a formal complaint against:

Name(s) of Person(s) Responsible (accused)	Grade / Role

If applicable, checkmark alleged basis of Harassment, Discrimination or Bullying Select all that may apply.

❏ Sexual Orientation

❏ Gender / Sex

❏ Ethnicity

❏ Race

❏ Racial/National Origin

❏ Religion

❏ Color

❏ Ancestry

❏ Mental or Physical Disability

❏ Age

❏ Sexual Harassment

❏ Marital Status

❏ Not Applicable

❏ Unsure

❏ Unknown

Describe the incident. What happened to you that caused you to ﬁle this complaint? Provide details of: Who?,

What?, Where?, When?, How?, and whether witnesses were present. (Attach additional pages if necessary)

List and attach to this complaint any supporting documentation, such as emails, screenshots, text messages, etc. WARNING: Do not attach any explicit photographs or videos. Please describe photographs or videos in detail in the narrative. Photographs and videos will be requested for viewing if necessary.
Type	Description	Date

List All Name(s) of Person(s) with Knowledge of the Incident	Grade / Role

Is there anyone who could provide more information regarding this complaint? Please list:	Grade / Role

Have you attempted to discuss your complaint with any District personnel? If so, with whom and what was the result?

What outcome would you like to see for this situation?

By signing below, I attest that all information on this form is accurate and true to the best of my knowledge. I understand that as a result of my ﬁling a formal complaint the school district will conduct an investigation into this matter.

Signature of Complainant Date

Signature of Translator (if applicable) Date

Forward copy of complaint to appropriate District Level Compliance Oﬃcer/Coordinator Immediately. If a possible Title IX violation, a copy of this form should be sent to the District Title IX Coordinator.

Received by:

Title:

Date:

Attachments

No attachments.