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     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.   

    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.
     
     
    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.  
       
    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).
     
     
       
    Please provide names and contact information for any witnesses to this incident.

     
       
    *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.