Sexual Misconduct Intake Form 10 21 11 by 2VuOzX

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									                                     The College at Brockport

                                    Sexual Misconduct Incident
                                     Intake and Referral Form

Name of person filing the report: _______________________________ Date: _______________

Name of College employee conducting intake:

Date(s) & Time(s) of Incident(s):

Location(s) of Incident(s):



Complainant

Name:

Email Address

Mailing Address:



Phone Number:



Accused

Name:

Email Address

Mailing Address:



Phone Number:



 Brief Description
Names/phone numbers of Witnesses:




Interim Measures Taken:



Current Status of Complaint:



Outcome of Complaint:




Names of People Consulted:



Follow-up with Complainant/Resource’s provided:



General Notes:



Complaint reported/referred to (Please circle all that apply):

       University Police
       Student Conduct Coordinator
       Title IX Deputy Coordinator for Students
       Affirmative Action Office
       Office of Human Resources
       University Police
       Counseling Center
       Student Health Center
       Rape Crisis Center
       Other: _______________________________

                         Email completed form to mreed@brockport.edu or abarone@brockport.edu.
    You may also bring the form to Residential Life/Learning Communities in Thompson Hall. Office phone: 585-395- 2122.

								
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