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Sexual Misconduct, Discrimination, Harassment, and Retaliation (Title IX)
/ Title IX Complaint Form
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Sexual Misconduct, Discrimination, Harassment, and Retaliation (Title IX)
Resources
Sexual Harassment/Sexual Assault
Immediate Assistance:
University of Arkansas at Pine Bluff Police Department
Emergency Contact: 870-575-8102
Tonisha N. Davis
Director of Affirmative Action
Title IX Coordinator
Delta Annex, Room 112
P: 870-575-8052 | F: 870-575-4753
titleix@uapb.edu
Monica R. Smith
Title IX Deputy Coordinator
Delta Annex, Room 112
P: 870-575-8555 | F: 870-575-4753
samuelssmithm@uapb.edu
Title IX Complaint Form
Full Name
Student/Employee ID #:
Are you a...
Student
Employee
Vistor
A contact phone number?
E-mail
Date of Incident
*
(Date of Incident is required)
Approximate time of the incident.
*
(Approximate time of the incident. is required)
Location of the incident.
*
(Location of the incident. is required)
What type of incident was it?
Sexual Misconduct
Sexual Harassment
Stalking
Dating/Domestic Violence
Was the act committed by a...
Student
Faculty Member
Staff Member
Someone Affiliated with the University
Someone Not Affiliated with the University
Explain what happened...