Title IX/Discrimination & Harassment Report

Reporter Information

Your full name or anonymous: (Required)

Your Student ID Number:

Preferred phone number:

Your email: (Required)

Reason for this report: (Required)
—Please choose an option—Report about a studentReport about faculty, staff or affiliateReport about non-student

Date of incident: (Required)

Time of incident:

Location of incident: (Required)
—Please choose an option—Off CampusOn CampusOnline

Reason(s) for Report

Types of sexual misconduct or discrimination & harassment experienced (check all that apply) (Required)
Dating ViolenceDomestic ViolenceSexual AssaultSexual Harassment: Quid Pro QuoSexual Harassment: Hostile EnvironmentSexual ViolenceStalkingAge DiscriminationColor DiscriminationQualified Disability DiscriminationGender Identity DiscriminationGenetic Information DiscriminationNational Origin DiscriminationOther DiscriminationPregnancy DiscriminationRace DiscriminationReligion DiscriminationRetaliationSexual ExploitationSexual MisconductSexual Orientation DiscriminationStatus as a Veteran Discrimination

Please explain the incident, including names and dates. (Required)

Please identify and briefly describe any other incidents you believe may be related to this report.

What other departments or agencies are involved or have been contacted about this report, if applicable. Such as Health & Wellness Services, CMN Security, Lighthorse Police, etc.

Describe the resolution you are seeking, relating to this report. If you are a reporter or mandatory reporter, type n/a. (Required)

Complaint Acknowledgement: (Required)
I want to file a report at this time. I want to talk to Civil Rights Compliance Coordinator before deciding whether to file a formal complaint. I understand by selecting this option that I have NOT filed a formal complaint with the Title IX Coordinator.I want to file a formal complaint of sexual harassment/discrimination or harassment. I authorize the Civil Rights Compliance Coordinator to assess the allegations described above.I am a Mandatory Reporter, Reporter, or Witness.

Statements of Understanding

I understand and consent to the disclosure of information contained in this report to appropriate administrators and witnesses interviewed for the purpose of investigating this complaint. I am willing to cooperate fully in the investigation and provide whatever evidence the College deems relevant. I understand that the nature of this report, correspondence, and all discussions conducted in the course of investigation of the information contained in this report are confidential to the extent permitted by law and College policy, and unauthorized disclosures of information concerning the investigation could result in disciplinary action. By submitting this form, I certify to the best of my knowledge the information that I have provided is accurate and the events and circumstances are as I have described them.

I have read and understood these statements.