University of Detroit Mercy Title IX Complaint/Intake Form

University of Detroit Mercy Title IX Complaint/Intake Form

Contact Information

Complainant Name: / (Student) (Employee)
Phone Number: / ( ) / Cell Phone Number: / ( )
Email Address:
Respondent Name: / (Student) (Employee)

Information Needed for Title IX Assessment

Question: / Do you feel that you are currently at risk for continuing harassment or misconduct by Respondent? Yes No
If “yes”, Explain:
Question: / Do you feel that you are at risk for retaliation by Respondent? Yes No
If “yes”,
Explain:
Question: / Have you received or reviewed University of Detroit Mercy 1.) Policy Prohibiting Sex and Gender-based Discrimination and 2.) Title IX Investigation and Resolution Procedure online? Yes No
Question: Would you like assistance in seeking an advisor to accompany you during investigation and resolution? Yes No
______
Question: Have you received or reviewed Care and Support Resources listed in the University Policy Prohibiting Sex and Gender-based Discrimination? Yes No
If “no”, would you like to review or discuss Care and Support Resources with the Office of Title IX? Yes No
Question: Have you contacted anyone else for help regarding this complaint? Yes No
If “yes”, please provide name, title, and date of persons contacted: (Example: local police, University Public Safety)______

Details of Incident involving Respondent (Person Alleged to Violate University Policy Prohibiting Sex and Gender-based Discrimination) and Any Supporting Documentation

Please list date(s) offensive behavior began or occurred: ______
Provide details of offensive behavior or events in your own words:
______.______
______
Supporting Documentation: (examples: photographs, images, emails, text messages, social media or other digital communication):
______I am attaching the following supporting documentation (if any): ______

Please feel free to attach additional sheets of information or documentation in support of your claim.

Thank you for taking the time to complete this form for reporting to the Title IX Coordinator. The University is committed to prompt resolution of complaints in a manner consistent with the University of Detroit Mercy Policy Prohibiting Sex and Gender-based Discrimination, and University of Detroit Mercy Title IX Investigation and Resolution Procedure. Thank you for providing your contact information so that we may follow up with you. We will make every effort to protect your confidentiality and to respect the privacy of individuals listed or describedin your complaint to the greatest extent possible.

Complainant signature: ______Date: ______

Complaint received by: ______Date: ______

Complaint/intake form may be submitted to Marjorie Lang, Title IX Coordinator, , Fisher Administration Center, Office of Title IX, 5th floor, or by fax to 313.993.1534

Alternatively, complaint/intake form may also be submitted toa deputy Title IX coordinators as described below:

McNichols campus – complaints against students or employees:

• Monica Williams, Dean of Students, , Student Center, 1st floor, Dean of Student’s Office
• Lanae Gill, Director of Residence Life, Shiple Hall, 1st floor
• Adam Hollman, Assistant Director of Student Life, ,

Student Center, 1st floor

• Teri Kromrei, Associate Athletic Director, , Calihan, 1st floor

McNichols campus- complaints against employees:

• Netina Anding-Moore, Associate Director of Human Resources, , Fisher Administration Center, Human Resources, 3rd floor

Corktown campus –School of Dentistry – complaints against students or employees:

• Juliette Daniels, Associate Dean for Student Services & Enrollment Management, , Dental Administrative Building, 4th floor

Rivertown campus – School of Law – complaints against students or employees:

• Megan Jennings, Associate Dean of Students, , School of Law, Student Services, 1st floor

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