Sexual Misconduct Title IX Complaint Form

Affiliation with Colleges StudentEmployeeThird Party/BystanderOther

Contact Information (If you do not want to file anonymously)

First Name

Last Name

Phone

E-mail

Home Address

Home City

Home State

Zip Code

Campus Address

City

State

Zip Code

Suspect Information

First Name

Last Name

Nick Names

Address

City

State

Zip Code

Estimated Age

Physical Description

Details

Type of Harassment/Coercion/Force --Select-- Verbal Physical Verbal and Physical Other

Check all that apply

Rape

Statutory Rape

Harassment

Domestic and/or Dating Violence

Sexual Assault

Stalking

Retaliation

Exploitation

Other

If other, please describe

Suspect/Victim Relationship --Select-- Partner/Lover Ex-Partner/Lover Spouse Colleague/Co-Worker Instructor/Teacher Acquaintance Stranger

Threat of Death Yes No

Presence of Weapon Yes No

Weapon Description

Incapacitation by Drugs or Alcohol Yes No

If yes, please describe

Were you physically assaulted or injured? Yes No

If yes, please describe

What did the suspect say before, during and after the assault? (Please be as specific as possible.)

Nature of Assault: --Select-- Attempted Completed Vaginal Oral Anal

Place of Occurrence --Select-- Victim's Home Suspect's Home Unknown Home Car/Vehicle Workplace Park Outdoors Parking Lot Other

Do you plan to make a formal report to the police? --Select-- Yes No Not Sure

Are you in need of any assistance in filing a police report? --Select-- Yes No Not Sure

Please give a narrative of the sexual assault
(Please provide as much detailed information as possible.)

I have read and understand the policy and procedures of the Preventing Sexual Misconduct Policy (Policy 100.31). I understand if I knowingly provide a false complaint under this policy to a College/District official or intentionally mislead District officials who are involved in the investigation or resolution of a complaint I may be subject to disciplinary action. My signed form shall ascot as a release of information and consent to review my academic, financial aid, registration, medical documentation and other records that are related to my complaint. I further understand that if I file this report anonymously, IECC’s ability to conduct an investigation into the particular incident or pursue disciplinary action against the alleged perpetrator(s) may be diminished.

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