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

Director of Safety and Compliance, Title IX Compliance Officer (nondiscrimination on the basis of sex):
Cody Thompson
Phone Number: 740.699.3924
68094 Hammond Rd.
St. Clairsville, OH 43950
czthompson@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:

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

Email the the

Phone Number *

Email *

I am the: *

Complainant
Witness
Other

Supportive Measures Requested (only if you are the complainant):

Assistance Report to Law Enforcement
On/Off Campus Counseling
Victim Advocate Outreach
Faculty Notification

Any Additional Information: