Formal Complaint of Misconduct including Discrimination, Harassment and Assault

This Report provides community members with the opportunity to notify the College of prohibited conduct. This form is used to formally file a complaint of discrimination of any type.

Florida Southern College (the “College”) is committed to the principles of equal opportunity and seeks to establish and maintain an environment which ensures equal access to education for all College community members including students, applicants for admission, employees, applicants for employment, guests, and visitors. To foster this environment, the College encourages individuals with knowledge or concerns of an incident of discrimination to report the incident.

In this document, you will see various terms. The definitions of these terms are below:

Anonymous Reports

The College accepts anonymous reports, which will be reviewed by the Title IX Co-Coordinator(s) and included in campus safety assessments. If an anonymous report is submitted by a third-party and contains the identity of the complainant, the Title IX Co-Coordinator will contact the complainant to inquire about the incident, offer supportive measures, and explain the process for filing a formal complaint. If an anonymous report does not contain the identity of the complainant, the College will be unable to contact the complainant and offer supportive measures. While the Title IX Co-Coordinator will keep confidential the identity of the complainant (unless disclosing the complainant’s identity is necessary to provide supportive measures such as no-contact orders), the Title IX Co-Coordinator must know the identity of the complainant to offer supportive measures.

Any person (the actual complainant or a third party) may report anonymously using the appropriate anonymous reporting form. However, the College’s ability to respond to anonymous reports is significantly limited.

Complaints of Sexual Discrimination

In accordance with the Florida Southern College Policy on Sexual Misconduct & Sexual Harassment, any person may report an incident(s) of sex discrimination, sexual misconduct, or sexual harassment to the Title IX Co-Coordinator(s). Forms of sexual harassment include sexual assault, dating violence, domestic violence, and stalking. The reporting party may be the person directly affected by the alleged incident (referred to as “complainant”) or a third party.

Regarding complaints of sexual harassment, it is important to note the following:

See the Sexual Misconduct & Sexual Harassment Policy for more information about the College’s complaint resolution procedures as well as the Title IX formal complaint and grievance process.

Contacts

If you have questions about filing a formal complaint, we encourage you to contact one of the Title IX Co-Coordinators. The Title IX Co-Coordinators’ contact information is as follows:

Once the report is received, the Title IX Co-Coordinator will contact the complainant to discuss supportive measures and explain how to file a formal complaint and/or initiate the complaint resolution procedures, if applicable and desired by the complainant. Supportive measures will be available to complainants regardless of whether or not they wish to file a formal complaint to initiate a Title IX grievance process or complaint to initiate the College’s grievance procedures.

Complainants, respondents, and reporters may also contact Counseling Services, if desired, which can be found on pages 30 & 31 of the Sexual Misconduct & Sexual Harassment Policy.

Thank you for filing a formal complaint. You can find additional resources about the College’s policies and protocols regarding incidents of discrimination, including sexual harassment on our website.

Complainant Information

*First Name:

*Last Name:

*Complainant Type:

*Email Address:

Phone Number:

( ) -

Address 1:

Address 2:

City:

State:

ZIP Code:

Ethnicity (Hispanic or Non-Hispanic):

Race of Complainant:

Gender of Complainant:

Position/Title:

Department:

Direct Supervisor:

Office Phone Number:

( ) -

Office Phone Extension:

Basis of the Complaint

Respondent Information

*Name:

*Gender:

*Race:

*Ethnicity (Hispanic or Non-Hispanic):

*This person is:

Position/Title:

Department:

Direct Supervisor:

Office Phone:

( ) -

Description of Complaint

*Description of Complaint:

Please describe in detail the incident(s) you consider to be discriminatory or retaliatory and why you believe this person discriminated or retaliated against you. Also, please provide the date(s) and locations(s) for each incident including first and last names of individuals involved. Explain why you have contact with these individuals (supervisor, co-worker, faculty, customer, etc.).

Complaint Documentation:

Do you have any documentation supporting your complaint such as text messages, print screens, or e-mails? If so, please provide copies of the documentation supporting your complaint along with any explanation behind the documentation.

Complaint Documentation Attachment 1:

Complaint Documentation Attachment 2:

Complaint Documentation Attachment 3:

Previous Action:

Have you brought this matter to the attention of any other person or department at the college or any external agency such as law enforcement or the EEOC? If so, please list the name(s) and department(s) of all other persons with whom you have discussed this matter and when you had the discussion.

*Corrective Action Sought:

Describe the relief or corrective action you are seeking from the college and/or the respondent.

Witnesses

Name:

Email Address:

Phone Number:

( ) -

How do you know the witness?:

Name:

Email Address:

Phone Number:

( ) -

How do you know the witness?:

Name:

Email Address:

Phone Number:

( ) -

How do you know the witness?:

Authorization and Signature

I understand that by submitting this formal complaint, I am knowingly initiating the formal grievance process (i.e. formal investigation) related to the allegations that have been described.

I understand that upon receipt of this formal complaint, the Title IX Co-Coordinator may contact me to gather additional information, if necessary.

I understand that upon the Title IX Co-Coordinator’s review, the College will dismiss a formal complaint of sexual harassment under Title IX if the alleged conduct:

I also understand that if a formal complaint of sexual harassment under Title IX is dismissed, the Title IX Co-Coordinator will notify the respondent and me of the dismissal. However, the behavior that does not meet the above criteria may still be addressed under different College policies.

By typing my name below, I confirm that I am the person making this formal complaint. I also confirm that the information provided in this formal complaint is true to the best of my knowledge.

Formal Complaint of
Misconduct
including Discrimination, Harassment and Assault

Introduction

Anonymous Reports

Complaints of Sexual Discrimination

Contacts

Amanda Blount, Ed.D.

Katherine Pawlak

Complainant Information

Basis of the Complaint

Respondent Information

Description of Complaint

Witnesses

Authorization and Signature