Adopted: March 2022
Revised: July 2023
Download 503.5.1P Formal Complaint of Sexual Harassment under Title IX
In accordance with Administrative Regulation 503.5AR (Title IX Sexual Harassment Grievance Process), District 196 prohibits sexual harassment under Title IX. Persons who believe they have been subjected to sexual harassment as defined by Title IX (and the parents or guardians of such persons) may use this form to make a formal complaint of sexual harassment to the District 196 Title IX Coordinator. This form may also be used by the Title IX Coordinator to institute a formal complaint of sexual harassment under Title IX. Formal complaints of sexual harassment under Title IX will be processed using the procedures detailed in Administrative Regulation 503.5AR.
If you do not wish to file a formal complaint at this time, but would still like to report sexual harassment to the Title IX Coordinator, do not use this form. Please contact the Title IX Coordinator (see contact information below) to discuss.
Name of person making report (please print)
Home address
Work address
Home phone (_____) ___________________ Work phone (_____) ___________________
Date(s) of alleged incident(s)
School(s) or District 196 program(s) involved _______________________________
Name of person you believe sexually harassed you or another person:_______
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If the alleged sexual harassment was toward another person, identify that person: _____________________________________________________________________________________
If the alleged sexual harassment was toward another person, are you the parent or guardian of that person: □ Yes □ No
List any witnesses who were present or who may have relevant information:
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Where and when did the incident(s) occur? ________________________________
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Describe the incident(s) as clearly as possible, including such things as what force, if any, was used; any verbal statements (i.e., threats, requests, demands, etc.); what, if any, physical contact was involved, etc. (Attach additional pages if necessary.)
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This complaint is filed based on my honest belief that
has sexually harassed me or another person. I hereby certify that the information I have provided in this complaint is true, correct and complete to the best of my knowledge and belief. I am requesting that the district investigate this matter and process it as a formal complaint of sexual harassment under Administrative Regulation 503.5AR.
Signature of Person Making Report X Date
For District 196 Use Only: Date Report Received ________
Please submit this form to the District 196 Title IX Coordinator:
Shelly Monson, Director of Human Resources
3455 153rd Street West
Rosemount, MN 55068-4946
Shelly.monson@district196.org
651-423-7859