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TITLE IX COMPLAINT FORM
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Email
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Your email
SECTION I: PERSON FILING COMPLAINT
Person Filing Complaint:
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Employee
Parent
Student
Student's Duly-Authorized Representative
Third Party
Title IX Coordinator
Full Name:
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Your answer
Address:
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Your answer
City:
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Your answer
State:
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Your answer
Zip Code:
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Your answer
Telephone:
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Your answer
Alternate Telephone Number:
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Your answer
Email Address:
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Your answer
SECTION II: ALLEGED VICTIM INFORMATION
Full Name:
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Your answer
Category:
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Employee
Student
Third Party
Student Date of Birth (if applicable):
MM
/
DD
/
YYYY
Address (if known):
Your answer
Telephone Number (if known):
Your answer
Student/Employee School Name or Work Location:
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Your answer
Employee Number (if applicable):
Your answer
Region (if known):
North
West
East
South
SECTION III: COMPLAINT DETAILS
Date(s) of Incident(s):
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Your answer
Location(s) of Incident(s):
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Your answer
Frequency of Incident(s):
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Your answer
Full Name(s) of Person(s) Accused:
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Your answer
Role/Relationship(s) of Accused Person(s) to Student:
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Employee
Student
Third party
Required
How did you learn of the alleged misconduct?
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Your answer
Is the complainant currently participating or was attempting to participate in a District program or activity at the time of the alleged violation?
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Yes
No
Name of Program or Activity:
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Your answer
Full Name of Witness(es):
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Your answer
SECTION IV: DESCRIPTION OF THE CONDUCT
Was the conduct sexual in nature?
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Yes
No
Maybe
Was the conduct severe (describe the specific nature of the alleged act(s)?
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Your answer
Was the conduct pervasive (i.e., how many times did the conduct occur; how many other people were involved)?
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Your answer
Was the conduct subjectively and objectively offensive? In other words, did the complainant/target perceive the conduct as offensive, and would a reasonable individual of similar characteristics (i.e., sex/gender, age, etc.) find the conduct offensive?
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Your answer
Did the conduct effectively limit or deny the complainant/target equal access to participate in or benefit from LAUSD’s education programs or activities?
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Your answer
SECTION V: REPORTING AND FOLLOW-UP ACTIONS
Has the complainant/target discussed the complaint concerns with any District personnel? Who and what was the outcome?
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Your answer
Have the parties received any supportive measures (e.g., modification of schedule, contact restrictions, deadline extensions, counseling, restorative activities, etc.)?
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Your answer
Is the complainant/target open to resolving the complaint through informal resolution measures?
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Yes
No
If the complainant/target is open to resolving the complaint through informal resolution measures, please describe the suggested remedy(s):
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Your answer
SECTION VI: COMPLAINANT ACKNOWLEDGMENT
By electronically signing and dating this form, I acknowledge that I am filing a Title IX complaint and am requesting to initiate the grievance procedure under Title IX. I was provided with written
grievance procedures
and a prompt and fair investigation into the conduct will begin. Note: Under certain circumstances, the parties may voluntarily agree to an informal resolution at any time throughout the grievance process.
Signature of person filing:
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Your answer
Date:
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MM
/
DD
/
YYYY
Send me a copy of my responses.
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