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Title IX Complaint Form

Title IX Complaint Form

(Including sexual misconduct)

 

Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681) is an all-encompassing federal law that prohibits discrimination based on the gender of students and employees of educational institutions which receive federal financial assistance.

To file a complaint with the University, please complete and submit this form in person to the Office of the Dean of Students or the Office of Human Resources or call to make arrangements for a representative to meet with you at another location. If you are unable for any reason to complete this form and would like to make a verbal complaint, please call one of these offices, but in order for a complaint to be official it must be in writing. 

When this form has been completed and signed by the complainant, and then signed by the Title IX Coordinator or a Deputy, the formal complaint has been properly received by the University. The complainant will be provided with a copy of this form as well as complete information about the Title IX complaint process.

Office of the Dean of Students

 203 Smith-Brown Memorial Student Union
 
PO Box 13405
Baton Rouge, LA  70813
Phone:  (225) 771 - 3922
Fax:  (225) 771 - 2202
Email:  dos@subr.edu
 
Web:  www.subr.edu/dos

Office of Human Resources

1st floor, J.S. Clark Administration Annex Building
PO Box 10400
Baton Rouge, LA  70813
Phone:  (225) 771-2680
Fax: (225) 771-5617
Web:  www.sus.edu/humanresources 
 

Although the University cannot commit to keeping a Title IX complaint confidential because of the University's obligation to investigate the complaint, the University will use its best efforts not to disseminate information concerning the complaint beyond those who have a need to know.

Southern University's Statement of Non-Discrimination

In compliance with Title IX of the Education Amendments of 1972, Title VI and VII of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and other federal, state, and local laws, Southern University and A&M College forbids discriminating or harassing conduct that is based on an individual's race, color, religion, sex, ethnicity, national origin or ancestry, age, physical or mental disability, sexual orientation, gender identity, gender expression, genetic information, veteran or military status, membership in Uniformed Services, and all other categories protected by applicable state and federal laws.   This commitment applies but is not limited to decisions made with respect to hiring and promotion, the administration educational programs and policies, scholarship and loan programs, and athletic or other College administered programs. Discriminatory acts of any kind are strictly forbidden.

Any member of the Southern University and A&M College community has the right to raise concerns or make a complaint regarding discrimination without fear of retaliation.  Any and all inquiries regarding the application of this statement and related policies may be referred to:  Marcus A. Coleman, Dean of Students, Title IX Coordinator, at (225) 771 - 3922 or Andrea Benjamin, Training Director, Deputy Title IX Coordinator, at (225) 771 - 2680.  Complaints may also be made via email at titleix@subr.edu or by visiting www.subr.edu/titleix

As set forth in our policies, individuals may also file complaints with administrative agencies such as the U.S. Department of Education, Office for Civil Rights.  The contact information for the local office of OCR is (214) 661-9600 is at Office for Civil Rights, Dallas Office, U.S. Department of Education, 1999 Bryan Street, Suite 1620, Dallas, TX 75201-6810.  The email address for OCR is OCR.Dallas@ed.gov.

WHO ENFORCES TITLE IX?

The United States Department of Education's Office for Civil Rights (OCR) is in charge of enforcing Title IX. Information regarding OCR can be found at www.ed.gov/about/offices/list/ocr/index.html.

 COMPLAINTS UNDER TITLE IX

Students:

If you are a student who believes you have been subjected to any form of discrimination under Title IX, you may report such misconduct or file a formal complaint with the Office of the Dean of Students or the Office of Human Resources. Complaints must be submitted in writing not more than 120 days after the incident(s) in question.

If you are a student who believes you have been or are the victim of sexual misconduct, including sexual assault, sexual harassment, sexual violence or other sexual misconduct, by another Southern University student or an employee, you may report such conduct or file a complaint under Title IX with the Office of the Dean of Students or the Office of Human Resources.

Employees:

If you are an employee who believes you have been subjected to discrimination under Title IX, including sexual harassment, or who wishes to file a complaint under Title IX, you can do so with the Office of the Dean of Students or the Office of Human Resources.  The formal complaints must be submitted in writing not more than 120 days after the incident(s) in question.

Federal and state laws prohibit the taking of retaliatory measures against any individual who files a complaint in good faith.

TITLE IX CONTACT INFORMATION

Marcus A. Coleman, Dean of Students & Title IX Coordinator
Office of the Dean of Students
Phone: (225) 771-3922
Fax: (225) 771-2202  
Email: marcus_coleman@subr.edu  

Ryan E. Tucker, Associate Dean of Students & Deputy Title IX Coordinator for Student Conduct
Office of the Dean of Students
Phone: (225) 771-5545
Fax: (225) 771-2202
Email: ryan_tucker@subr.edu  

Andrea Benjamin, Deputy Title IX Coordinator for Human Resources
Southern University System Office of Human Resources
Phone: (225) 771-5789
Fax: (225) 771-5617
Email: andrea_benjamin@sus.edu

Pamela Smith, Deputy Title IX Coordinator for Athletics  
Department of Athletics
Phone: (225) 771-5908
Fax: (225) 771-4400
Email: Pamela_smith@subr.edu

  

 

Report filed by:
Victim/Survivor
Third Party
Anonymous

COMPLAINANT INFORMATION

 

Check one:
Student
Faculty
Staff
Applicant (Student/Employee)
Other
Name

(First Name)

(Last Name)
S-Number
Gender
Race
Local Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Campus Email
Classification

(If a student)
Major

(If a student)
Position/Title

(If an employee)
College/Dept:

(If an employee)

TYPE OF COMPLAINT

 

Check all that apply
Age
Bullying (Cyber-Bullying)
Disability
Gender
Marital Status
Medical Condition
National Origin
Race
Retaliation
Religion
Sexual Assault
Sexual Misconduct
Sexual Orientation
Stalking
Veteran Status
Other

RESPONDENT INFORMATION (Person you believe to be responsible for the alleged act)

 

Name
Gender
Race
The respondent is:
Student
Faculty
Staff
Other
Position/Title:

(If an employee)
College/Dept

(If an employee)
Your relationship to the respondent

(If any)
Date/Time of the alleged incident:
Location of alleged incident:

WITNESSES (Relationship information requested means co-worker, supervisor, faculty, etc)

 

Witness 1 Name
Witness 1 Relationship
Witness 1 Phone
Witness 2 Name
Witness 2 Relationship
Witness 2 Phone
Witness 3 Name
Witness 3 Relationship
Witness 3 Phone

Has this incident been reported to any other department(s) at the University?

 

Has this incident been reported
Yes
No
(If yes, provide the following:)
College/Department:
Contact Person
Department Location
Phone
Was the incident reported to law enforcement?
Yes
No
If yes, what agency?

Describe in detail your complaint (Attach additional sheets if necessary)

 

Your complaint

Describe the corrective action you are seeking (Attach additional sheets if necessary)

 

Corrective Action
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