Fillable Compliance Office Title IX Complaint Form (Mohave Community College)

Fill Online, Printable, Fillable, Blank Compliance Office Title IX Complaint Form (Mohave Community College) Form

Use Fill to complete blank online MOHAVE COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Compliance Office Title IX Complaint Form (Mohave Community College)

On average this form takes 15 minutes to complete

The Compliance Office Title IX Complaint Form (Mohave Community College) form is 5 pages long and contains:

  • 0 signatures
  • 15 check-boxes
  • 52 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Mohave Community College

BROWSE MOHAVE COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Compliance Office
Title IX Complaint Form
Complainant Demographics
Name:
Mailing Address:
Email Address:
Primary Phone:
Campus Location:
Department (if employed by MCC):
Affiliation to the College:
Student/Employee ID:
Complaint Information
I believe I was subject to:
Discrimination
Harassment
Because of my (check all that apply):
Race
Color
Age
Gender Identity
Pregnancy
Genetic Information
Sexual Orientation
Sex (Gender)
Religion
Citizenship
Marital Status
National Origin/Ancestry
Disability
Services in the Uniformed Services or Covered Veterans
Other (please specify):
I believe I have been sexually harassed:
Yes
No
I believe I was subjected to retaliation:
1
MCC Form ADM_0029 (1-28-15)
Compliance Office
Title IX Complaint Form
Yes
No
Date of alleged discrimination/harassment/retaliation:
Place of alleged discrimination/harassment/retaliation:
Respondent’s Demographics
Name(s):
Affiliation to the College:
Department (if employed by MCC and if known):
Witness Demographics
Name(s):
Status of witness(es) if known:
Information Reported
Have you reported the incident to the police?
Yes
No
If you are a MCC employee, have you filled a grievance pursuant to Human Resources?
Yes
No
Have you filed a complaint with a government agency other than MCC’s Human Resources
Department regarding the incident?
Yes
No
If yes, please indicate the agency name and date the complaint was filed.
2
MCC Form ADM_0029 (1-28-15)
Compliance Office
Title IX Complaint Form
Resolution
What would you consider to be a successful or acceptable outcome/resolution to your complaint?
Please indicate any special requests:
Complaint
Please state your complaint:
3
MCC Form ADM_0029 (1-28-15)
Compliance Office
Title IX Complaint Form
Attestation
By signing this form, I hereby certify that every statement I have made in this application is true
and complete to the best of my knowledge. I understand that the College prohibits students and
employees from knowingly making false complaints and breaking this rule will result in
disciplinary action. I understand that all College employees are mandatory reporters and cannot
promise confidentiality. I understand that the Title IX Coordinator and Team attempts to balance
the needs of the parties for privacy with the institutional responsibility of ensuring a safe
educational environment and workplace. I understand that the College prohibits students and
employees from retaliation, intimidation, threats, coercion or discrimination against any
individuals for exercising that individual’s rights or responsibilities. I understand that acts of
retaliation constitutes a violation of the College policy and Student Code of Conduct and will
result in disciplinary action. I am aware that any such acts of discrimination should be reported to
the Campus Dean/Title IX Coordinator/Title IX (students) or for employees the immediate
supervisor or the Director of Human Resources.
Complainant Signature:
Date:
All Title IX Complaint Forms should be emailed to the MCC Title IX email: Titleix@mohave.edu
4
MCC Form ADM_0029 (1-28-15)
Compliance Office
Title IX Complaint Form
For Office Use Only
Interview
Interview Notes:
Identifier Name, ID (e.g. Smith, 123456):
Date:
Investigation
Investigation Recommendations:
Investigator Name:
Date:
5
MCC Form ADM_0029 (1-28-15)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Compliance Office Title IX Complaint Form (Mohave Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document