Title IX Complaint Form

Complainant First and Last Name *

Complainant Contact Email *

Complainant Student or Staff ID Number *

Complainant's School *

Grade or Position of Complainant * Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th Grade 6th grade 7th grade 8th grade 9th Grade AcadeMir Charter Schools Support Staff AcadeMir Charter Schools Instructional Staff AcadeMir Charter Schools Administrator

Accused First and Last Name *

Accused School * AcadeMir Charter School West AcadeMir Charter School Middle AcadeMir Preparatory Academy AcadeMir Charter School Preparatory AcadeMir Charter School of Math and Science AcadeMir Middle School of Math and Science AcadeMir Charter School East at Doral AcadeMir Charter School East Middle AcadeMir Charter School Elementary South AcadeMir Preparatory Academy

Date of Alleged Incident *

If the alleged incident happened more than once: List the alleged incident time frame *

Have you brought this matter to the attention of any other staff? *

List of Witnesses to the alleged incident *

Type of Title IX Claim * Dating Violence Gender Discrimination Gender Inequality Sexual Assault Sexual Harassment Sexual Misconduct Stalking

Where did the incident occur? * On Campus Off Campus Both on and Off Campus

I acknowledge that, by checking the box, the information I have provided will determine the scope of the investigation. I have reviewed the entirety of this complaint submission and affirm that, to the best of my knowledge, the information provided is true and accurate. I understand that knowingly submitting false information may result in disciplinary action against me.

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