Title IX

Date*

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email*

Please select your title*

Current Building*

Have you talked to the building principal or immediate supervisor to try to resolve the problem?*

Yes
No

Do you understand the statement below?*

Yes
No

You are required to cooperate fully with any investigation conducted by Johnston Community School District. You may not knowingly file a false complaint. If you knowingly provide untruthful or inaccurate statements, you may subject yourself to disciplinary action, up to and including termination.

Do you understand the statement below?*

Yes
No

Retaliation against any person, because the person has filed a complaint or assisted or participated in an investigation, is prohibited. Persons found to have engaged in retaliation shall be subject to discipline by appropriate measures.

Do you want to file a complaint?*

Yes
No

Against who?*

Do you need to add another person to your complaint?*

Yes
No

The allegation is:*

On what basis?*

Nature of discrimination or harassment*

District policy:
102.1: Title IX: Discrimination & Harassment based on Sex Prohibited

What parts of the policy do you believe are being violated?*

When did this alleged treatment begin?*
MM slash DD slash YYYY

Type full name*
First Last

Consent*
I agree that the above statements are true.

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What is Title IX?

Title IX Complaint Form