Title IX Incident Report Form

This form is to be used by students and employees to report incidents to MCC. Employees, as a reminder, you must complete and submit this form as soon as possible after learning of an incident that may violate the Title IX policy.

Your Name Your Title Your Email Your Phone Date, Time, and Location of Incident Date Incident Reported to You

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Complainant, Reporting Victim, or Reporting Third Party
Their Name, Contact Information (phone, email, address) Against Whom (Accused/Perpetrator/Suspect)
Their Name, Contact Information (phone, email, address) Name and Contact Information of Person Who Reported the Incident to You
(optional; if different from the complainant)

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Description of the Incident
Please be as specific as possible and include facts shared by the complainant, names of witnesses, if available. Case Status
Measures taken; how did you leave things with the victim? Offices Involved
Has victim reported the incident to the police? Has victim filed an internal complaint? Is victim working with an outside agency? Have you shared this information with any other offices?

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Has the Title IX Checklist been reviewed with Complainant?

YesNo

Has the Complainant requested confidentiality?

YesNo

Is the incident Clery Act reportable?

YesNo

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