title vi programs and activities discrimination complaint form

If you believe you or anyone else is in immediate risk to health or safety, call 911 or WVSU Public Safety at (304) 766-3181.

As members of the WVSU community we each have a responsibility to report behaviors that potentially constitute discrimination, harassment or misconduct. We encourage any person who personally experiences such behavior or becomes aware of others experiencing such behaviors to utilize this form to notify the University, specifically the Office of EEO/Title IX.

The Complainant or Reporter should submit this completed form when they believe them self or another individual has been subjected to unlawful participation in any University program or activity based on their race, color or national origin.

Even when unsure if a specific behavior constitutes a violation of program and activity participation practices, you can still complete and submit the complaint form. You can also submit your complaint directly to:

Carolyn L. Stuart, PhD
217 Ferrell Hall
PO Box 1000
Institute, WV 25112
carolyn.stuart@wvstateu.edu
(304)-204-4018

Once the form is submitted, it will be sent to the Title IX Office for review and appropriate response.

BACKGROUND INFORMATION
Your Full Name:
Your Position/Title:
Your Phone Number:
Your email:
Your Physical Address:
Nature of This Report:
Date of Incident:	Today
Time of Incident:
INVOLVED PARTIES Please list all individuals involved including as many of the listed fields as you can provide.
Name or Department:
Gender:
Role:
Phone Number:
Email Address:
Mailing Address:
Please check all behaviors alleged to have occurred:
Provide a description of the incident or conduct being reported:
SUPPORTING DOCUMENTATION Please attach any supporting documentation, if applicable.
Upload file:

title vi programs and activities discrimination complaint form

BACKGROUND INFORMATION

INVOLVED PARTIES

SUPPORTING DOCUMENTATION

Events Calendar