Title IX Complaint Form
TITLE IX COMPLAINT FORM
As outlined in the School’s Title IX Policy and Grievance Procedures, consistent with Title IX of the Education Amendments of 1972 (“Title IX”), the Fort Mill School District does not discriminate on the basis of sex in its educational programs and activities, recruitment, admissions, course offerings, financial aid, athletics, or employment.
INSTRUCTIONS: Individuals alleging Title IX discrimination or harassment and requesting review under the Fort Mill School District’s Title IX Policy and Grievance Procedures, are encouraged to complete this form and submit it to the District’s Compliance Coordinator as soon as possible after the occurrence of the alleged discrimination or harassment. This form should only be used for complaints alleging sex-based discrimination, harassment, and/or violence prohibited by Title IX and as outlined in the District’s Title IX Policy and Grievance Procedures. For all other complaints, please consult the relevant policies in the School’s Student Handbook, as applicable.
COMPLIANCE COORDINATOR INFORMATION:
Name: Cori Hustedt, Director of Student Services
Amy Maziarz, Senior Executive Director of Special Services
Liza Stouffer, Assistant Superintendent of Human Resources and Educator Effectiveness
Address: 2233 Deerfield Drive, Fort Mill, SC 29715
Telephone Number: 803-548-2527
Email Address: hustedtC@fortmillschools.org
maziarza@fortmillschools.org
stoufferl@fortmillschool.org
COMPLAINANT INFORMATION:
Name: ___________________________________________________________ _
Department/Title: ________________________________
School/Grade: _____________________________________________________
Home Address: _______________________________________________
Telephone Number: _______________________________________________________
Email Address: ___________________________________________________________
Today’s Date: ____________________________________________________________
PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE REGARDING YOUR COMPLAINT BELOW. 1. Name of person(s) you believe committed the offense(s) against you and how you know the person(s). ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
2. Nature of Grievance: Please describe the action and/or conduct that you believe may be sex-based 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 and where did the actions described above occur? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
4. Were there any witnesses to this action/conduct? (Please Circle) Yes No If yes, please identify the name and contact information for all witnesses: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
5. Did you discuss this matter with any of the witnesses identified in Item 4? (Please Circle) Yes No If yes, please identify the name of the person(s) who you communicated with, the date(s) on which the communication occurred, and the method(s) of communication: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
6. Have you spoken to any School Administrator(s) or other School employee(s) about this matter? (Please circle) Yes No If yes, please identify the name of the person(s) who you communicated with, the date(s) on which the communication occurred, and the method(s) of communication: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
PLEASE ATTACH ANY ADDITIONAL INFORMATION OR DOCUMENTATION WHICH YOU BELIEVE IS RELEVANT TO YOUR COMPLAINT. The information provided in this complaint is true and correct to the best of my knowledge. I am willing to cooperate fully in the investigation of my complaint and provide whatever evidence the School deems relevant and/or necessary to investigate this matter.
Signature of Complainant: _____________________________________
Date: ______________
Signature of Parent/Guardian (if submitted on behalf of student under the age of 18): ___________________________________________________________
Date: _______________
Print Name of Parent/Guardian: ___________________________________________________