Title IX Incident Report Form
**If this is an emergency, please call 911**
Reports will remain anonymous by simply not filling out Reporting Party Information.
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| Reporting Party Information |
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| First Name: |
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| Last Name: |
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| Contact Phone Number: |
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| Contact Email Address: |
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| Are you a: |
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| May we contact you at this phone number? |
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| Responding Party Information |
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| Type of Complaint: |
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Please identify the person(s) of whom your
complaint is made.
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| Name: |
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| Contact Information: |
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| Is this person a: |
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| Title/Department (if applicable): |
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| Relationship/Association to you: |
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| Name: |
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| Contact Information: |
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| Is this person a: |
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| Title/Department (if applicable): |
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| Relationship/Association to you: |
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| Name: |
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| Contact Information: |
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| Is this person a: |
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| Title/Department (if applicable): |
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| Relationship/Association to you: |
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*If you are a third party reporting this incident, please do not include the victim's contact information unless it is their wish to do so.
*Victims including contact information should expect to be contacted by the Title IX Coordinator to initiate an investigation. |
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| Complaint |
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| *Please be advised that any information you share regarding specifics of the incident will be provided to the responding party. |
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Please provide details about the incident. Include date/time/location(s).
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Please provide names and contact information for any witnesses to this incident.
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| *If you have provided contact information, you will be contacted by the Title IX Coordinator. |
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Coastal Bend College does not discriminate on the basis of race, creed, color, national origin, gender, or disability.
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