Title IX Policy Violation Reporting Form

Today's Date *

Name of Reporter

Reporter Status

Reporter's Contact Information

Name of Complainant (The individual who is alleged to be the victim of conduct that would constitute Prohibited Conduct under Manor's Title IX Policy)

Complainant's Status

Name of Respondent (The individual who allegedly engaged in conduct that would constitute Prohibited Conduct under Manor's Title IX Policy)

Respondent's Status

Date / Time of Incident: *

Date

Time

Location(s) of Incident: *

Name and contact information of any Witnesses (along with their status as either student, faculty, staff, visitor, or unknown)

Description of Incident: *

Administrators notified, if any (Check all that apply):

Administrator (e.g. Dean of Students, etc)
Health Services (please note that these individuals are confidential resources and are not “responsible employees” of manor as prescribed in the Sexual Misconduct Policy (aka Title IX policy))
Counseling Services (please note that these individuals are confidential resources and are not “responsible employees” of manor as prescribed in the Sexual Misconduct Policy (aka Title IX policy))
Public Safety
Title IX Coordinator
Campus Chaplain (including student chaplains)
Faculty

Police called: *

Yes
No

Emergency Services called: *

Yes
No

If yes to either police or emergency services called, please provide the Officer’s Name and Badge number/ or the emergency services contact information.

Electronic signature and date:

Terms of Acceptance and signature: I, the reporter of this form, warrant the truthfulness of the information provided above. I understand that checking the box constitutes a legal signature confirming that I acknowledged and agree to the Terms of Acceptance. *

Acceptance