PECOS CYBER ACADEMY TITLE IX COMPLAINT FORM

PECOS CYBER ACADEMY TITLE IX COMPLAINT FORM
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 that receive federal financial assistance. When the form has been completed and signed by you, and then signed by the Title IX Coordinator or a Deputy, your complaint has been properly received and noted by the Central Consolidated School District. We will provide you with a copy of this form as well as complete information about the Title IX complaint process. Please use this form to report incidents of sexual discrimination/harassment you have experienced, witnessed, or have had reported to you. Completion of this form does not constitute an open investigation. Once this form is completed and has been received, an initial assessment will be conducted to determine if the report rises to a level that warrants further investigation.
DATE OF REPORT

MonthDayYear
Date
What is your association with this incident?

It happened to me.I observed the incident.I am a student and I have information about the incident.I am an employee and I have the information about the incident.I have information about the incident but I am not a student or an employee.Other
If other, please give an explanation:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Alleged Incident

MonthDayYear
Date
Time of Alleged Incident

Hour Minutes

AM/PM Option
Address of Incident

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please provide a detailed description of the alleged harassing incident(s) using specific concise, objective language (who, what, where, when, why, and how).
If you have any other documentation such as text messages, photos, documents, etc, please attach below.

Cancelof

Do you have any reason to believe this incident(s) represents an immediate threat of harm or danger to the individual or other members of the campus community?

YesNo
Have you reported this incident(s) to any other departments?

YesNo
If yes, to whom did you report it? CCSD employee, HR, Supervisor, Administration, Law Enforcement, Social Worker, etc.
Was anyone injured?

YesNo
If yes, describe the injuries:
What actions or remedy would you like to see as a result of this report?
Thank you for bringing this incident to our attention. PCA will respect the privacy of the complainant, the individual(s) against whom the complaint is filed and the witnesses as much as possible, consistent with legal obligations to investigate, take appropriate action, and conform to any legal discovery or disclosure. Any information gathered during an informal procedure may be used during a formal procedure, if initiated. While there can be no assurances of complete confidentiality, complaints under this procedure will be treated as sensitive information not to be shared with others except in limited circumstances. Decisions regarding confidentiality will be made by the Title IX Team consistent with PCA policy and Title IX regulations as amended August 1, 2024.
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