Title IX – Discrimination/Harassment Incident Reporting Form

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Today's Date

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How Can We Reach You?

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Your Phone Number

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Your Home Address

Street Address

Address Line 2

City

State

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Your Department Name and Phone Number (for employees)

Your Position/Title (for employees)

Persons Involved

Please use this section to list the names of the parties involved as well as any witnesses, etc. Enter as much information as possible. If you have included your name above, it is not necessary to add it to this section.

Name or Organization

Role(e.g. Accused, Affected Individual, Witness)

Email/Phone Number

Name or Organization

Role(e.g. Accused, Affected Individual, Witness)

Email/Phone Number

Name or Organization

Rolee.g. Accused, Affected Individual, Witness

Email/Phone Number

Report Details

Incident Details

Date of Incident

Time of Incident

Specific Location of Incident

Have you notified anyone else or any other campus or non-campus unit about this incident? If yes, whom did you notify?

Provide as much detail as you are comfortable with concerning the incident. This will be reviewed by the appropriate staff/faculty member at Alamance Community College.