Title IX Formal Complaint Form

This form should be completed and submitted by the person who has allegedly experienced a Prohibited Conduct, in violation of our Policy. If you are a Responsible Reporter or Third Party Reporter, please complete the Title IX Reporting Form.

Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681) is a federal law that prohibits discrimination on the basis of sex of students and employees of educational institutions which receive federal financial assistance. When this form has been completed and signed by you, and then signed by the Title IX Coordinator, your complaint has been properly received and noted by the University. The Formal Complaint Form is required to initiate the formal resolution process (investigation and hearing or informal resolution).

We will provide you with a copy of this form as well as complete information about the Title IX complaint process. If you require emergency assistance, please call security at: (302) 857-7911.

You may complete, sign and file this Title IX Formal Complaint form by sending it to the DSU Title IX Coordinator in person, by mail, email or online.

Mijrane Belizaire, JD
Title IX Coordinator
302.857.6374
titleIX [at] desu.edu

COMPLAINANT INFORMATION

Type: *

Type: Other...

Name:

First:

Last:

D-Number:

Gender:

Local Address:

Country *

Address 1 *

Address 2

City *

State *

ZIP code *

Home Phone:

Cell Phone:

Work Phone:

Campus Email:

(If a student) Classification:

Major:

(If an employee) Position/Title:

Department:

Type of Complaint:

Type of Complaint: Other...

RESPONDENT INFORMATION

Person you believe to be responsible for the alleged act

Name:

First:

Last:

Gender:

The respondent is:

The respondent is: Other...

(If an employee) Position/Title:

College/Dept:

Your relationship to the respondent (if any):

Date of the alleged incident:

Month

Day

Year

Time of the alleged incident:

Hour

Minute

AM/PM

Location of alleged incident:

WITNESSES

Relationship information requested means co-worker, supervisor, faculty, etc

Witness 1:

Relationship:

Phone:

Witness 2:

Relationship:

Phone:

Witness 3:

Relationship:

Phone:

Has this incident been reported to any other department(s) at the University?

If yes, provide the following:

College/Department:

Contact Person:

Department Location:

Phone:

Was the incident reported to law enforcement:

If yes, what agency?

Describe in detail your complaint:

For retaliation complaints, please explain why you believe someone retaliated against you.

Describe your feelings when the incident happened and the corrective action you are seeking:

Complainant Certification

I request that the University conduct an investigation into the allegations of sexual harassment described above.

I certify that this information is true and correct.