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Title IX Formal Complaint Form

This form should be completed and submitted by the person who has allegedly experienced a Prohibited Conduct, in violation of our Policy. If you are a Responsible Reporter or Third Party Reporter, please complete the Title IX Reporting Form.

Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681) is a federal law that prohibits discrimination on the basis of sex of students and employees of educational institutions which receive federal financial assistance. When this form has been completed and signed by you, and then signed by the Title IX Coordinator, your complaint has been properly received and noted by the University.  The Formal Complaint Form is required to initiate the formal resolution process (investigation and hearing or informal resolution).

We will provide you with a copy of this form as well as complete information about the Title IX complaint process. If you require emergency assistance, please call security at: (302) 857-7911.

You may complete, sign and file this Title IX Formal Complaint form by sending it to the DSU Title IX Coordinator in person, by mail, email or online.

Mijrane Belizaire, JD 
Title IX Coordinator 
302.857.6374
titleIX [at] desu.edu 

 

COMPLAINANT INFORMATION

Name:
Local Address:

RESPONDENT INFORMATION

Person you believe to be responsible for the alleged act

Name:
Date of the alleged incident:
Time of the alleged incident: :

WITNESSES

Relationship information requested means co-worker, supervisor, faculty, etc

If yes, provide the following:

For retaliation complaints, please explain why you believe someone retaliated against you.

Complainant Certification

I request that the University conduct an investigation into the allegations of sexual harassment described above. 

I certify that this information is true and correct.