Your full name:
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Phone number:
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Email address:
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Mailing address:
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Alleged violation of Title IX and Policy Against Harassment and Discrimination (select all that apply):
Are any of these protected statuses the basis for the alleged policy violation(s)? (select all that apply):
Location of incident:
Victim(s) name(s):
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Victim(s) contact information [as available - name, phone, email, address, social media username(s)]:
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Witness(es) name(s):
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Witness(es) contact information [as available - name, phone, email, address, social media username(s)]:
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Describe the incident(s) or event(s). What happened? Describe your actions and reactions. Who else saw or heard? Include date(s), time(s), and location(s).
What impact has/have the incident(s) or event(s) had on you?
Have you taken any action to stop the behavior?
What remedy do you seek?
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