Complaint Form

Date

Complainant Name

Address

Street Address

City

State

Zip Code

Country

University Address

Complainant E-mail

Home Phone Number

Select One

StudentEmployee

Discrimination based on: (please select)

sex (including sexual harassment and assault, domestic violence, dating violence and stalking)sexual orientationgender identity

Describe the specifics of complaints including dates of alleged discrimination or sexual misconduct

Describe any corrective action that you are seeking with regard to the alleged discrimination or sexual misconduct

Provide the name/s against whom your complaint is filed (when possible, please note title)

If anyone witnessed these events, please list their names, titles and a summary of what you believed they witnessed:

Full Name

Title

Summary

-

Full Name

Title

Summary

-

Full Name

Title

Summary

Please confirm

To the best of my knowledge, I affirm that all of the factual information on this form is accurate.

Submitted forms go to the Office of Social Equity

210 Carrier Hall, Clarion University of Pennsylvania, Clarion, PA 16214

Title IX Coordinator: