MINERAL AREA COLLEGE

Sexual Harassment / Title IX Incident Reporting Form

THIS FORM IS FOR REPORTING NON-EMERGENCY INCIDENTS ONLY

FOR EMERGENCIES, INCLUDING SAFETY CONCERNS FOR MEMBERS OF OUR COMMUNITY, CALL THE MAC CAMPUS POLICE AND SECURITY DEPARTMENT AT 573-631-2831 OR DIAL 911.

First Name:

Last Name:

MAC Employee/Student ID Number:

Your position/title:

Your phone number:

Your email address:

Your physical address:

Date of Incident:

Time of Incident:

Location of Incident:

Specific location:

INVOLVED PARTIES

Please list the names of the individuals and/or organizations in this incident, including as many of the listed fields you can provide.  Be sure to include anyone connected to this incident or that has been contacted regarding this incident. "Complainant" refers to the individual for whom the action was directed towards, and "Respondent" refers to the individual allegedly engaging in the behavior/policy violation. 

Involved Party 1

Name or Organization:

Role:

ID Number:

Date of Birth:

Phone Number:

Email Address:

College Park Address:

Involved Party 2

Name or Organization:

Role:

ID Number:

Date of Birth:

Phone Number:

Email Address:

College Park Address:

Involved Party 3

Name or Organization:

Role:

ID Number:

Date of Birth:

Phone Number:

Email Address:

College Park Address:

Involved Party 4

Name or Organization:

Role:

ID Number:

Date of Birth:

Phone Number:

Email Address:

College Park Address:

Involved Party 5

Name or Organization:

Role:

ID Number:

Date of Birth:

Phone Number:

Email Address:

College Park Address:

Involved Party 6

Name or Organization:

Role:

ID Number:

Date of Birth:

Phone Number:

Email Address:

College Park Address:

QUESTIONS

Please provide a detailed description of the incident/concern using specific, concise, objective language.
(Who, what, where, when, why, and how)

How did you leave things with the victim?

Has the victim reported the incident to the police, or filed an internal complaint? If so, please provide details.  If no information has been shared, please indicate so.

Have you shared this information with other officers? If so, please provide details.  If no information was has been shared, please indicate so.

Has the checklist been reviewed with the Complainant?

Has the Complainant requested confidentiality?

Is the incident Clery Act reportable?

What date was this incident reported to you?

SUPPORTING DOCUMENTATION

Photos, videos, email and other documents may be attached below:

Please select a file:

Please select a file:

Please select a file: