Title IX Complaint Form

This form may be used to file a report of sex discrimination, sex/gender based harassment, sexual harassment (including sexual assault, dating violence, domestic violence and stalking) and other forms of prohibited conduct pursuant to the College’s Sexual Misconduct Policy. You may use this form if you believe you have been discriminated against based on sex, sexual orientation, gender, gender identity, pregnancy, status as a victim of dating violence, domestic violence, stalking, other sex offenses, retaliation, or any other legally prohibited basis in accordance with Federal, State and City Laws. In addition, you may use this form to report any incident of alleged sexual harassment (including but not limited to Title IX sexual harassment), sex/gender-based harassment, sexual assault, dating violence, domestic violence, stalking, voyeurism or other forms of sexual misconduct as defined in the College’s Sexual Misconduct Policy.

All reports are submitted to the Title IX Coordinator. You may also contact the Title IX Coordinator directly:

Bill Boerner

Interim Title IX Coordinator

179 Livingston Street

Brooklyn, NY 11201-9902

Phone: (718) 489-2019

Email: billboerner@sfc.edu

Reports of sex discrimination, including sexual harassment can be made to the Title IX Coordinator at any time, including during non-business hours, by using this report form. Any person can make such a report by mail, by telephone, or by electronic mail, using the Title IX Coordinator’s contact information listed above, or by any other means that results in the Title IX Coordinator receiving the individual’s verbal or written report.

Information is shared with additional parties on a need to know basis depending on the facts. However, the identities of the individual making the report, the alleged victim, the alleged respondent, and all witnesses will be kept confidential, except as may be permitted or required by law, or to conduct any investigation, hearing, or judicial proceeding.

Individuals reporting information to the College are protected from retaliation. Please note that submission of this form does not, on its own, constitute filing a formal complaint. If you wish to file a complaint regarding an allegation of prohibited conduct under the College’s Sexual Misconduct Policy, please contact the Title IX Coordinator.

Submission Date and Time

DateHourMinutesAM/PM Option

1. Today's date:*

Date

2. Date of alleged incident:*

Date

3. If the alleged misconduct occurred on multiple dates please list them here:

4. Your Name:*

First NameLast Name

5. Phone Number:

Area CodePhone Number

6. Email:*

Confirmation Emailexample@example.com

7. You may choose to report information to the Title IX Coordinator while also choosing to remain anonymous.

YesNo

8. How were you affected?*

DirectlyWitnessThird Party Non-WitnessOther

9. If you were witness to an alleged incident, please provide the name of the alleged victim below.

10. Alleged Respondent's Full Name:*

11. Location of Incident (please specify if on-campus or off-campus):*

12. Alleged Discrimination, Harassment or Sexual Misconduct (check all that apply)*

13. Please describe the events, facts, or other bases for your report:*

14. Please list any witnesses or individuals with information regarding the allegations (provide names and contact information)

15. Have you reported this incident to anyone else? If so, who?*

16. What is your role?*

17. Do you need assistance with academic or workplace accommodations?*

YesNo

18. Are you familiar with the supportive measures available, including but not limited to No-Contact Orders?*

YesNo

19. Are there any services/resources that you are interested in knowing more about:

20. Additional Comments/Notes/Impact Statement:

12. Questions or Concerns:

Reporting Form