Title IX Complaint Form

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Liberty Elementary School District (“the District”) complies with federal and state laws prohibiting unlawful discrimination based on race, color, national origin, sex, disability and age in its programs and activities. Any person that believes they have been harassed or discriminated against based on his/her sex can file a complaint under this procedure by contacting the appropriate school level Title IX Coordinators as follows:

● Name

● Title IX Coordinator - Dr. Stephanie Mohorne - Assistant Superintendent of Human Resources & Student Services

● address

● phone (with extension if applicable)

● email address

Email *

Date

YYYY

Complainant Name

Address

Phone number

Respondent Name (person whom complaint is against)

Describe the alleged sexual harassment in specific terms (attach additional pages if necessary).

Include:

a. The specific incident or activity that is alleged to be in violation of Title IX

b. The name of all individuals involved;

c. Dates, times, and locations involved.

Describe any relevant communication that has already occurred to address the issue. Please specify the types of communication, dates of communication, and names of individuals with whom any communication has occurred.

Do you want this Complaint to be formally investigated and addressed by the School?

Yes

Clear selection

If “No”, please clarify:

I do not want a formal investigation. I am just bringing this to the School’s attention

I do not want a formal investigation. I would like to speak with the Title IX Coordinator about my complaint.

Other:

Clear selection

Electronic Signature (first and last name)

Date signed

YYYY

Submit

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This form was created inside of Liberty Elementary School District.