Student Title IX Formal Complaint Form

STUDENT TITLE IX FORMAL COMPLAINT FORM

Student Title IX Contact:
Ms. Derika Hodge
Associate Dean of Students
Email: dhodge@suscc.edu
Name:

First NameLast Name
Student A Number:
Example, A012345678
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your relationship to the college:
Example, Student
Respondent Name:

First NameLast Name
Respondent Relationship to You:
Date of Event:

MonthDayYear
Time of Event:
Example, 8:00 AM
Campus:
Building Name:
Room Number:
Describe the Alleged Incident:
How would you like the Situation Resolved:
Signature:
Please verify that you are human
Should be Empty: