Identify your relationship with Lenoir Community CollegeIdentify your relationship with Lenoir Community College:FacultyStaffStudentEmployment ApplicantOther
Other
Student/ Employee ID #
First Name
Last Name
Academic Year
Department
Email Address
Primary Phone Number
Secondary Phone Number
Home Address
City
State
Zip
Have you brought this matter to the attention of any other department(s) at LCC? List the name(s) and department(s) of all other persons with whom you have discussed this matter.
AgeColorDisabilityGenetic InformationNational OriginPolitical AffiliationRace/EthnicityReligionRetaliationGender IdentitySexSexual HarassmentSexual OrientationSexual AssaultVeterans StatusOtherPregnant/Parenting Rights
Describe your complaint and include relevant dates that the alleged behavior occurred. Please summarize below.
Is the behavior ongoing?Select OneYesNo
If so, when is the last time it occurred? mm/dd/yy
Name of person or persons who engaged in the conduct giving rise to your formal complaint and your relationship with them (e.g. classmate, teammate, supervisor, co-worker, faculty)
Date(s) of conduct
Location(s) of conduct
Name of witness(es) and your relationship to them. Please include contact information if known.
Additional Information:
Are you requesting that LCC investigate your allegation(s) of Sexual Harassment under its Title IX Sexual Harassment Grievance Procedures?Select OneYesNo
Do you certify that the above information is correct?Do you certify that the above information is correct?YesNo
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TODAY'S DATE
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Student Complaints and Grievances: Dr. Kimberly Hill Dean of Student Services/Title IX Coordinator Administration (Building 003) Room 140C Phone: (252) 527-6223, ext. 301 Fax: (252) 233-6893 Email: krhill01@lenoircc.edu
