Title IX Initial Complaint Form

Toledo Public Schools
Title IX Initial Complaint Form

The purpose of this Title IX Complaint form is to gather the essential basic facts of the alleged actions in order to facilitate prompt and equitable resolutions of complaints of sexual harassment prohibited by Title IX of the Education Amendments of 1972 (“Title IX”). This form applies only to complaints alleging sexual harassment and/or retaliation related to sexual harassment, with sexual harassment defined as conduct on the basis of sex that satisfies one or more of the following: a quid pro quo; unwelcome conduct so severe, pervasive and objectively offensive that it effectively denies a person equal access to the School Board’s education program or activity; sexual assault; dating violence; domestic violence; and/or stalking.

Toledo Public Schools (TPS) does not discriminate on the basis of sex in any education program or activity that it operates as required by Title IX. The district also does not discriminate on the basis of sex in admissions or employment.

Retaliation is an adverse action taken against an individual because they engaged in a protected activity, such as complaining about discrimination, threatening to file a charge of discrimination, or participating or refusing to participate in investigative proceedings. Retaliation is prohibited by law, regulations, and School Board policies.

Persons are strongly encouraged to report allegations of sexual harassment to the District Title IX Coordinator. However, you may also submit your complaint to the school’s Principal or Title IX Liaison, or the work-site supervisor. You may submit your complaint via fax, e-mail or U.S. Mail to the District’s Title IX Coordinator using the contact information below.

For additional information about Title IX or any other discrimination/harassment concerns, contact the U.S. Department of Education Assistant Secretary for Civil Rights and/or:

The TPS Equity, Diversity and Inclusion
Department

Title IX Coordinator
Dr. Amerah Archer
Equity, Diversity and Inclusion Department
419-671-0881
[email protected]

Website: https://www.tps.org

Custom Form

1. I am filing this complaint as:
Employee
Student
Parent/Guardian
Third-Party (e.g. Applicant)

2. Complainant(s): Please provide the name of the person(s) who is alleged to be the victim of conduct that could constitute sexual harassment or retaliation related to sexual harassment or Complainant(s):
a. Name of Parent/Guardian, if Complaint is a minor:

3. Student ID/Employee ID (if applicable):

4. Grade (if applicable):

5. Email Address:

6. Home Address:

7. Telephone No.:

8. School Name/Work Location (if applicable):

9. Please select the type of complaint you are making:
Sexual Harassment
Retaliation

10. Date(s) of the alleged incident(s):

11.Approximate time(s) of the alleged incident(s):

12. Location of the alleged incident(s):

13. Date of Report Made at School-Site or Work-Site and the Name of the Administrator to Whom the Report Was Made (if applicable):

14. Please provide the name of the person(s) who you believe committed the offense, i.e. Respondent(s), against the Complainant and their relationship to the Complainant (e.g. classmate, colleague, staff member, etc.).

15. Complaint: Describe your complaint. Please provide as much information as possible.

16. For retaliation complaints ONLY, please answer questions 16(a) and 16(b) below:
a. Please explain the protected activity (e.g. filing a complaint of sexual harassment, opposing sexual harassment, serving as a witness to a sexual harassment complaint, etc.) forming the basis for this retaliation Complaint:

b. Please explain the retaliation alleged:

17. Witnesses: Please list the names of any witnesses along with any relationship you share with this witness (e.g. co-worker, classmate, teacher, non, etc.)

18. Does evidence exist? If so, what type (e.g. text messages, photos, videos, etc.)? Please keep and preserve these materials.

19. List any supportive measures being requested.

20. Is there anything else you would like us to know?

I certify that the information provided in this complaint is true and correct to the best of my knowledge. I understand it is a violation of School Board Policy JFCF-R and the Code of Student Conduct to provide false statements. I understand that full cooperation in an investigation of this complaint will assist the District in an efficient and effective response to the complaint.

Signature:
Printed Name:
Date:

Signature of Parent/Guardian (if applicable):
Printed Name:
Date:

 

 

For Internal Use Only
Case #: 

Title IX Coordinator/Deputy Title IX Coordinator: 

FM-7803E Rev.



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