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 | |
First Name: | |
Last Name: | |
Contact Phone Number: | |
Contact Email Address: | |
Are you a: | |
May we contact you at this phone number? | |
Responding Party Information | |
Type of Complaint: | |
Please identify the person(s) of whom your complaint is made. |
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Name: | |
Contact Information: | |
Is this person a: | |
Title/Department (if applicable): | |
Relationship/Association to you: | |
Name: | |
Contact Information: | |
Is this person a: | |
Title/Department (if applicable): | |
Relationship/Association to you: | |
Name: | |
Contact Information: | |
Is this person a: | |
Title/Department (if applicable): | |
Relationship/Association to you: | |
*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 | |
*Please be advised that any information you share regarding specifics of the incident will be provided to the responding party. | |
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. | |
Coastal Bend College does not discriminate on the basis of race, creed, color, national origin, gender, or disability. |