Title IX Discrimination Complaint
(including gender equity, sexual harassment and sexual violence)
California State University, Northridge (CSUN) in accordance with Title IX of the Education Amendments of
1972, prohibits discrimination on the basis of sex in education programs and activities. Under Title IX,
discrimination on the basis of sex can include sexual harassment or sexual violence.
CSUN does not tolerate sexual violence in any form. Sexual violence means physical sexual acts such as sexual
touching, sexual assault, sexual battery, rape, domestic violence, dating violence, and stalking (when based on
gender or sex) perpetrated against an individual against his/her will and without consent or against an
individual who is incapable of giving consent. Title IX protects all people regardless of their gender or gender
identity from sexual harassment and violence.
If you experience any of these forms of violence, you are strongly encouraged to utilize the various on and off
campus resources described in your Rights and Options.
Policies and procedures for reporting and responding Title IX complaints are contained in the University’s
Notice of Non-Discrimination on the Basis of Sex.
To file a complaint with the University, please complete and bring this form in person to the Office of Equity
and Diversity or call our office to make arrangements to meet with the Campus Title IX Coordinator.
Campus Title IX Coordinator
Susan Hua
Director, Office of Equity and Diversity
Telephone: (818) 677-2077
Office: University Hall (UN) 285
E-Mail: [email protected]
Although the University cannot promise complete confidentiality because of the University’s obligation to act
in situations that present a possible threat to the safety and well-being of the campus community, information
concerning the complaint will be safeguarded to the extent possible and will not be disclosed beyond with
those who have a legitimate need to know.
Rev. 7/23/2014
Title IX Complaint Form
Title IX of the Education Amendments of 1972 is a federal civil rights law that prohibits discrimination on the basis of sex in
education programs and activities. Under Title IX, discrimination on the basis of sex can include sexual harassment or sexual
violence, such as rape, sexual assault, sexual battery, and sexual coercion. Title IX protects all people regardless of their gender or
gender identity from sexual harassment and violence.
Please indicate your status or affiliation with CSUN.
Current Student
Student Alum(a/us)
Student Applicant
Current Faculty
Current Staff
Other: ___________________________
First Name: __________________________ Last Name: __________________________ Work Ext: _________________
Cell Phone: _________________ Home Phone: _________________ Email: ____________________________________
Mailing Address: ______________________________________ City: ___________________ State: _____ Zip: ________
Student ID: _____________ Class Standing: ________
Employee ID: ____________ Position Title: ________________________________
Department: ________________________________Supervisor Name: ________________________
Have you brought this matter to the attention of any other department(s) at the university? If so, please list the name(s)
and department(s) of all other persons with whom you have discussed this matter.
TYPE OF COMPLAINT: (check one or more)
AGE
ANCESTRY
COLOR
DISABILITY
GENDER/GENDER IDENTITY OR EXPRESSION
GENETIC INFORMATION
MARITAL STATUS
MEDICAL CONDITION
PREGNANCY
RELIGION
RETALIATION
VETERAN STATUS
OTHER (Explain): _______________________________
RACE
SEXUAL ORIENTATION
NATIONAL ORIGIN
SEX
SEXUAL HARASSMENT
DATE of alleged discrimination/harassment (or last in series of alleged discriminatory/harassing acts): _______________
NAME OF PERSON or persons you believe discriminated against you and why you have contact with them, e.g.
supervisor, co-worker, faculty, classmate.
COMPLAINT: Please summarize your complaint below. If necessary, attach additional pages, including any documents
and other information you wish to be considered in resolving your complaint.
Provide the following details:

Specific allegations;

All facts relevant to your complaint (who, what, when, where);

Names of any witnesses (if any) including their contact information and relationship to you.
Note: All contacts with potential witnesses regarding this complaint are to be made only by the E & D
investigator;

The specific relief or remedy you are seeking.
For retaliation complaints, please explain why you believe someone retaliated against you:
I certify that the information I have provided in this complaint is true and correct.
Your Signature: _____________________________________________________ Date: __________
(Rev. 5/30/2014)