Title IX Report

Title IX Report Form

Instructions: Please complete this form with detailed information about the potential Title IX violation. All provided details will be given privacy to the greatest extent possible without otherwise impairing appropriate Title IX actions and activities.

Examples of violations to report: Quid pro quo harassment, hostile work environment on the basis of sex, sexual assault, stalking, dating violence, and domestic violence.

Please be sure to attach any additional information you feel might be helpful for us to know or review.
Do you have immediate safety concerns? CALL 911!
The Title IX Coordinator or a Deputy Coordinator will review and assess the report and take appropriate action. Thank you for promoting a discrimination-free environment.

Please complete the following information. You may check "I wish to remain anonymous" to submit this form anonymously. Please note that anonymous reports and reports lacking sufficient information may negatively impact the College's ability to respond to or investigation a potential Title IX violation.

Reporting Person's Info:

I wish to remain anonymous

First Name:

Last Name:

Email Address:

Phone Number:

Victim Info:

Alleged Victim Name (enter N/A if unknown):

Alleged Victim Relationship to College:

Violator Info:

Alleged Violator Name (enter N/A if unknown):

Alleged Violator Relationship to College:

Incident Details:

Approximate Date of Incident:

Description of incident:

Were there additional witnesses to the incident?

Location where incident occurred:

Attach any relevant documentation:

By submitting this form, I understand that the College may be obligated to take measures to address potential violations of Title IX, CCCC Code of Conduct, or other regulations as necessary. I understand that the College prohibits Retaliation against a reporting party. I also understand that if a reporting party makes a false accusation, the reporting party will be subject to appropriate disciplinary action.