Shady Grove Public School
PURPOSE: The purpose of this Title IX grievance form is to gather the essential basic facts of the alleged actions in order that, prompt and equitable resolutions of complaints based on sex discrimination, including complaints of sexual harassment or sexual violence, in violation of Title IX of the Education Amendments of 1972 (“Title IX”) can be resolved as expediently and appropriately as possible. This form only applies to complaints alleging discrimination prohibited by Title IX (including sexual harassment and sexual violence). INSTRUCTIONS: Individuals alleging Title IX discrimination and requesting review are required to complete this form and submit it to the appropriate administrator as soon as possible after the occurrence of the alleged discrimination: Contact our Title IX Coordinator: Emmett Thompson, 918-772-2511
Name of Complainant:_________________________
Home Address: _____________________________________________________________
City/State/Zip
Home Phone: __________________________
Student Grade:_____________
1. Location:_________________________________
2. Nature of Grievance: Please describe the action you believe may be sex discrimination, including complaints of sexual harassment or sexual violence, in violation of Title IX and identify with reasonable particularity any person(s) you believe may be responsible. Please attach additional sheets, if necessary: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
3. When did the actions described above occur? ________________________________________________________________________________________ ________________________________________________________________
4. Are there any witnesses to this matter? (Please circle) Yes No If yes, please identify the witnesses: ____________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________
5. Did you discuss this matter with any of the witnesses identified in Item 4? (Please circle) Yes No If yes, please identify: Person to whom you have spoken:___________________________________ Date:_________________ Method of communication: ____________________________________________________________________________ ____________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________
6. Have you spoken to any administrator(s) or other District employee(s) about this matter? (Please circle) Yes No If yes, please identify: Person to whom you have spoken:_______________________________ Date:___________________ Method of communication: ________________________________________________________________________________________ ________________________________________________________________ ____________________________________________________________________________
7. Please describe the result of the discussion(s) identified in Item 6: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ PLEASE ATTACH ANY STATEMENTS, NAMES OF WITNESSES, REPORTS, OR OTHER DOCUMENTS WHICH YOU FEEL ARE RELEVANT TO YOUR COMPLAINT. I certify that the foregoing information is true and correct. ____________________________ Print Name ______________________________ Signature ______________________________ Date