TITLE IX COMPLAINT FORM
Email address *
SECTION I: PERSON FILING COMPLAINT
Person Filing Complaint: *
Full Name: *
Address: *
City: *
State: *
Zip Code: *
Telephone: *
Alternate Telephone Number: *
Email Address: *
SECTION II: ALLEGED VICTIM INFORMATION
Full Name: *
Category: *
Student Date of Birth (if applicable):
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Address (if known):
Telephone Number (if known):
Student/Employee School Name or Work Location: *
Employee Number (if applicable):
Local District (if known):
Clear selection
SECTION III: COMPLAINT DETAILS
Date of Incident(s): *
Location(s) of Incident(s): *
Frequency of Incident(s): *
Full Name(s) of Person(s) Accused: *
Role/Relationship(s) of Accused Person(s) to Student: *
Required
How did you learn of the alleged misconduct? *
Is the student attempting to participate or currently participating in a District program or activity? *
Name of Program or Activity: *
Full Name of Witness(es): *
SECTION IV: DESCRIPTION OF THE CONDUCT
Was the conduct severe (describe the specific nature of the alleged act(s)? *
Was the conduct pervasive (i.e., how many times did the conduct occur; how many other people were involved)? *
Was the conduct objectively offensive or in other words would a similarly situated individual of like characteristics (i.e., age, developmental level, race, ethnicity, sex, etc.) find the conduct offensive? *
Did the conduct effectively deny the alleged victim equal access to an LAUSD educational program or activity? *
SECTION IV: REPORTING AND FOLLOW-UP ACTIONS
Have you discussed your complaint concerns with any District personnel? Who did you speak with and what was the outcome? *
Have the parties received any supportive measures (e.g., modification of schedule, contact restrictions, deadline extensions, counseling, etc.)? *
Are you open to resolving the complaint through informal resolution measures? *
Please explain if you are open to resolving the complaint through informal resolution measures: *
SECTION V: 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 (https://achieve.lausd.net/cms/lib/CA01000043/Centricity/Domain/383/Attachment%20L%20Title%20IX%20Protections.pdf) and a prompt and fair investigation into the conduct will begin. Note: All parties may voluntarily agree to an informal resolution at any time throughout the grievance process.
Complainant Signature: *
Date: *
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