Title IX Complaint Please fill out this form if you would like to formally file a Title IX Complaint Step 1 of 5 - Report filed by 20% Report filed by:*Victim/SurvivorThird PartyAnonymousCheck one:* Student Faculty Staff Applicant (Student/Employee) Other If you chose "Other" explain here: Name* A Number Gender Race Local Address City State ZIP Code Home Phone Cell Phone Work Phone Campus Email (If a student) Classification Major (If an employee) Position/Title: College/Dept Type of Complaint (Check all that apply) Age Bullying (Cyber-bullying) Disability Gender Marital Status Medical condition National Origin Race Retaliation Religion Sexual Assault Sexual Harassment Sexual Misconduct Sexual Orientation Stalking Veteran Status Other Respondent Name Gender Race The respondent is:* Student Faculty Staff Applicant (Student/Employee) Other If you chose "Other" explain here: (If an employee) Position/Title College/Department Your relationship to the respondent (if any) Date/time of the alleged incident Location of the alleged incident Witness 1Name Relationship Phone Witness 2Name Relationship Phone Witness 3Name Relationship Phone Has this incident been reported to any other department(s) at the University? Yes No College/Department Contact Person Department Location Phone Was the incident reported to law enforcement? Yes No If yes, what agency? Describe in detail your complaint*Describe your feelings when the incident happened and the corrective action you are seeking*