Complaint Form

Identify your relationship with Lenoir Community College:

Identify your relationship with Lenoir Community College

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.

Complaint Type: Select all that apply:

Describe your complaint and include relevant dates that the alleged behavior occurred. Please summarize below.

Is the behavior ongoing?

If so, when is the last time it occurred?

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):

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) and Location(s)of conduct

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??

Are you requesting that LCC investigate your allegation(s) of Sexual Harassment under its Title IX Sexual Harassment Grievance Procedures?

Do you certify that the above information is correct?

PRINT NAME

SIGNATURE

TODAY'S DATE

Please leave this field empty.

Student Complaints and Grievances:
Kim Hill
Dean of Student Services/Title IX Coordinator
Administration (Bldg 3), Room 140C
Phone: (252) 527-6223, ext. 301
Fax: (252) 233-6893
Email: krhill01@lenoircc.edu

Complaint Form

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