Please complete the following information as thoroughly as possible. Required fields are denoted by an asterisk. (*)

Indiana Tech Affiliation

Affiliation with Indiana Tech

If other, please explain below.

Complaint Information

Nature of Complaint: If other, please explain.

Person Whom you are Reporting Violated Title IX

Description of Complaint: Describe your complaint and why you believe this person discriminated /retaliated against you. Explain why you have contact with this person (e.g. supervisor, co-worker, faculty, customer, etc). Give date(s), time(s), and place(s) the discrimination/retaliation occured. (Attach additional pages as necessary.)

Previous Action: Have you brough this matter to the attention of any other department(s) at the university? If so, please list the name(s) and department(s) of all other persons with whom you have disscussed this matter.

Complaint Documentation: Explain any documentation supporting your complaint.

Corrective Action Sought: (Attach additional pages as necessary.)

Witnesses:(Relationship= co-worker, supervisor, customer, faculty, etc.)


I declare that the information submitted is true and accurate to the best of my knowledge and that false reporting for the purpose of slander or other malicious intent would be a violation in itself and have certain ramifications. Printing your name and submitting your birth date below will serve in lieu of your signature when completing this online complaint submission.”