Complaint Form

    Identify your relationship with Lenoir Community College:














    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?

    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


    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??

    Do you certify that the above information is correct?

    PRINT NAME

    SIGNATURE

    TODAY'S DATE



    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