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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 firstname.lastname@example.org or email@example.com. You may also bring the form to Residential Life/Learning Communities in Thompson Hall. Office phone: 585-395- 2122.
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