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Title IX Complaint Form

Return this form to:
Dr. Alley, TIX Coordinator
(660)359-3948 ext. 1400

In Person

NCMC Campus
Office 12, Alexander

Via Mail

1204 Main Street
Trenton, MO 64683


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Date of Report:____________________________
Complainant Name:_______________________________________________________________________

Contact Information:___________________________________________________________________________
(You may report the incident anonymously if you choose and are not required to provide any information which could expose your identity.)
Reported by:____________________________________________________________________________________

Does the survivor want to file a formal complaint with NCMC at this time:  YES   NO


Incident Information

What kind of incident are you reporting?

Sex Discrimination
Sexual Harassment
Sexual Violence
Other:_________________________

Is the incident ongoing?  YES   NO

How would you describe your relation to the College?

Student
Faculty/Staff
Visitor
Other:_________________________

Date/Time of Incident:____________________


Location of Incident:________________________________________________________________________
Name(s) of other person(s) involved and/or witnessess:
________________________________________________________________________________________________
________________________________________________________________________________________________
Brief description of the incident(s). You may attach additional information if necessary:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________


Reported by:____________________________________________________________ Date:____________________
Complainant Signature:__________________________________________________ Date:____________________
Title IX Coordinator:___________________________________________________ Date:___________________

The following have been offered:

___Copies of: Rights and Options, Resources, Title IX Policy
___Medical follow-up  ___Involvement of law enforcement  ___Consent to investigate
___Confidentiality  __Forms of support; interim measures