RECEI
KENT STATE UNIVERSITY
OFFICE OF COMPLIANCE, EQUAL OPPORTUNITY AND AFFIRMATIVE ACTION
GENDER & SEX DISCRIMINATION/SEXUAL HARASSMENT/SEXUAL MISCONDUCT
INTERNAL COMPLAINT FORM

COMPLETING THIS FORM INITIATES A FORMAL INVESTIGATION BY THE UNIVERSITY.
IN THE EVENT THE ACCUSED IS A STUDENT, THIS FORM WILL BE PROVIDED TO THE OFFICE OF
STUDENT CONDUCT AND SERVE A,S A COMPLAINT INITIATING THE STUDENT CONDUCT PROCESS.
A STUDENT CONDUCT HEARING WILL BE SCHEDULED AND YOU WILL BE CONTACTED USING THE
CONTACT INFORMATION PROVIDED BELOW.
Visit http://www.kent.edu/studentconduct;student-conduct-process for more information on the
student conduct process.
Policy 5-16,2 outlines the investigation process
COMPLAINANT'S NAME:

. EMAIL:

e...___. ________

.WhatJs the best �ay to reach you?_➔p_h_··....o....n
........
Student (Ple¥e 11st �I address)

Staff/facultyJPlease_ list job tide & Deparbnent/College name} __________________

.. .

'

Visitor/Applicant (Please'llstcurrent malling address).________________
PROTECTED CLASS
J'Gender/Sex

ALLEGED DISCRIMINATORY ACTION AREA (Place an @in the appropriate box(es) which best identify
the area{s) which you perceive are applicable to your complai\lt.)

□ Pregnancy
□ Stalking

�exual Harassment

□ Domestic Violence

□ Dating Violence
□ Sexual Misconduct

(When) Date(s) and time ofinciden& Af\:t.
(Where) Location{s) of incident: Of\

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□ Gender Discrimination

□ Gender Identity

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How many times did act or behavior this occur? (t'Qa;,U (fk-1 (Once, twice, reoccurring etc)
Is the act or behavior still continuing?_ yes _no

 If known, Respondent's (the person(s) that committed the act or behavior) name(s) & contact info of the person(s)
that committed the alleged discriminatory act/behavior or harassment:
(Email address, dept/college/school/phone number/residence ball etc.)

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DESCRIPTION OF THE ALLEGED DISCRIMINATION ACT OR BEHAVIOR: Please use the following
space to describe the discriminatory actions, behaviors or events which occurred. Be as precise
as possible with regard to the names of the Involved participants. names ofwitnesses. loc;ations.
and 1tami, (Use aclcliti()n3cI paper if11ecess�ry) PL,EASE ,N,OTE: A copy of thi� complaint will be
tiDlei,
provtaed to the accused party. Your Banner JD and contact information will be redacted.

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.N.a.k: The University will keep all information pertaining to the investigation as confidential as
possible. After filing a formal complaint with the university, the complainant's name and any
written statements submitte d may be disdosed to the accused. Relevant information disclosed
during the investigative process may be shared with the accused (and the student conduct hearing
panel or as part of an investigative summary, when applicable) in order to properly investigate
and adjudicate the complaint.
I have read arid understood this document. I affirm my responses in this complaint are accurate to the best of my knowledge
and this complaint has been m
______ Date: � / ' //
Complainant Signature:

9

Title IX Coordinator/Title IX Deputy Coordinator
or AA Facilitator Signature:___________________ Date:______