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Home › Title IX Complaint Intake Form

Title IX Complaint Intake Form

This form can be completed for purposes of filing a complaint of sexual misconduct under Title IX. Although we cannot guarantee complete confidentiality, Belmont College will take steps to keep an environment that is free from sex discrimination

Title IX Coordinator (nondiscrimination on the basis of sex)
Jason Huffman, Director of Human Resources
68094 Hammond Road
St. Clairsville, OH 43950
740.699.3836
jhuffman@belmontcollege.edu

Complainant's Information

Name *

First

Last

Phone Number *

Email *

Select one: *

Student
Employee
Other

Respondent's Information

Name *

First

Last

Phone Number *

Email *

Checkboxes *

Student
Employee
Other

Tell us more about the incident.

Where did it take place: *

When did it occur: *

What time did it occur: *

Describe the incident in as much detail as possible:

Are there any witnesses to the incident or anyone you have told about the incident? If so, please provide names:

another If

Was the incident reported to College Safety and Security, or another employee, or any law enforcement agency? *

Yes
No
Unknown

If College employee or other law enforcement agency, which one?

Form Completed by

Name *

First

Last

Phone Number *

Email *

I am the: *

Complainant
Witness
Other

Any additional information:

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68094 Hammond Road 
St. Clairsville, OH 43950

740.695.9500 tel

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