DRS Title IX Complaint Report

Please use this form to report an allegation of sex/gender-based discrimination, sex/gender-based harassment, sexual harassment (including sexual assault, dating violence, domestic violence, and stalking), sexual misconduct, or retaliation which are prohibited by Title IX and DHS policy.

This form is meant for use by students, parents or guardians, and members of the public. DRS personnel, vendors, consultants, and contractors are required to use the "Mandatory Procedure for Reporting a Complaint" protocol outlined in the IDHS Title IX Procedure Manual. Only a student, parent or guardian, or member of the public may choose to report an allegation anonymously using this form. Our ability to properly investigate an allegation depends on the information provided, so please provide us with as much information as you're able to.

We are not able to guarantee that your report will remain confidential. In certain instances, we may be required to disclose it by law.

You do not need to answer every question to submit the form. If you have any questions, please call the Title IX Coordinator at 312-848-4721 or email DHS.DRS.TitleIXCoordinator@illinois.gov.

Section 1 - Who is filling out this form?

Your name:

I am a: Student Parent Guardian Other

Email address:

Phone number:

Home address:

City, State, ZIP:

May we contact you for further information? Yes No

Section II - What happened?

Type of complaint: Discrimination Harassment Sexual Misconduct Retaliation

Date of incident:

Time of incident:

Location of incident:

Description of incident:

Witness names and contact information:

Were police notified? Yes No

Was medical care required or received? Yes No

Does evidence exist (e.g., texts, photos, video)? Yes No
If so, please keep those materials.

Section III - Who do you believe was harmed?

Person you believe was harmed:

What school do they attend: ISD ISVI ICRE-R

What grade are they in:

Additional persons who you believe were harmed:

Section IV - Who do you believe caused the harm?

Person you belive caused harm:

The person is a: Student Staff Member Someone from outside the school Family Member Other

If a student, what grade are they in:

If a staff member, what is their role at the school:
(e.g., principal, teacher, security guard, or coach)

Additional persons who you believe may have caused harm:

Section V - Do you have any other information you would like to share?

Is there anything else you would like to let us know: