Fillable INTAKE FORM TITLE IX REPORT INFORMATION (Meredith College)

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INTAKE FORM TITLE IX REPORT INFORMATION (Meredith College)

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2020 Meredith College
INTAKE FORM
TITLE IX REPORT INFORMATION
Welcome to Meredith College’s Title IX Report form. You may use the report to submit concerns regarding
sexual harassment, sexual assault, intimate partner violence, stalking, or other sexual misconduct. Please note
that this reporting system is not continuously monitored; accordingly, if this is an emergency, please call
Meredith College Campus Police at 919-760-8888 or local law enforcement at 911.
Use this form to record information needed for Title IX reporting purposes. This form and the accompanying
Title IX Information Checklist must be completed by a MC Title IX Coordinator or designee when meeting
with the reporting individual.
INCIDENT INFORMATION
Reporting Individual
Name:
Reporting Individual Status:
Student Employee Other
Reporting Individual
Local Address:
Telephone (Home):
(Cell):
Date of Incident:
Date College Became Aware of Concern:
Name of Accused:
Accused’s Status:
Student Employee Other
Location of Incident:
For Title IX Coordinator: Clery-covered Location?
Yes No
Have criminal charges been filed?
Yes No
Was a Student Conduct complaint filed at time of
notification?
Yes No
Today’s Date and Time:
College Official Name (required):
2020 Meredith College
TYPE OF ALLEGED HARASSMENT
Description of Alleged Harassment (including information on any witnesses):
Make Three Copies of this Report
Original: The Title IX Coordinator.
Copy: Copy for office records.
Complainant: Provide a copy upon request.
TITLE IX INFORMATION CHECKLIST
Reporting Individual Name: Date of Incident:
CRITICAL INCIDENT RESPONSE:
YES
NO
Do you want to receive medical services at Student Health Services located in Carroll Hall?
Do you want to receive medical services at a local hospital (Rex, Wake Med, etc.)?
Do you want to receive confidential counseling at the Counseling Center located in Carroll
Call or talk to the counselor on call?
Do you want to receive services from Interact in Raleigh?
Do you want to receive services from any of the other campus and community service
providers listed on the attached sheet? If yes, please describe:
Do you want to file a report with Meredith Campus Police, Raleigh Police Department, or
another law enforcement agency?
Other (Describe):
2020 Meredith College
We discussed information and options regarding the following measures (check all that apply and indicate
accommodations that are requested or in place at this time):
Room Lock Change
Change of housing for either accused or reporting
individual
Reasonable safety accommodations (including
security escort, or other accommodations)
Other (describe):
OFFICE VISIT FOLLOW-UP/DELAYED REPORT
YES
NO
Were you informed of where to find the Title IX and Other Prohibited Sexual Misconduct
Policy and a description of the grievance process?
Do you want to file a report with Campus Police, RPD, or another law enforcement agency?
Do you want to file criminal charges against the accused person?
Do you want to file a report or have you already filed a report with a Title IX Coordinator?
Do you want to file a complaint or have you already filed against a college employee or visitor
with any other office on campus?
Do you want to file a formal Title IX complaint at this time to initiate an investigation?
At this time, are you undecided as to whether you want to pursue any of the reporting options
available to you?
SUPPORTIVE MEASURES: WE DISCUSSED INFORMATION AND OPTIONS REGARDING THE
FOLLOWING MEASURES. (CHECK ALL THAT APPLY AND INDICATE ACCOMMODATIONS
THAT ARE REQUESTED OR IN PLACE AT THIS TIME.)
Restriction from contact with accused student (i.e.
mutual or one-way no contact order)
Change of housing for either accused or reporting
individual
Reasonable safety accommodations (including
security escort, or other accommodations)
Academic accommodations (such as alternate
classroom or schedule)
Room lock change
Academic support services; counseling services
Change in on-campus work assignment or work relocation or work hours adjustment (Describe):
2020 Meredith College
Other Actions (Describe):
INFORMATION
If you elect to file a report with law enforcement (MC Campus Police, the Police or another law enforcement
agency) an officer may conduct an investigation based on potential criminal activity related to the incident you
reported. You may also choose to consult a private attorney to explore legal options.
If you elect not to pursue or participate in disciplinary action (as applicable) through the Title IX and Sexual
Misconduct Policy, the College may determine it is necessary to pursue the complaint process without your
involvement. You will be notified if such an action is needed. In addition, the College may be required to document
this report for Clery Act statistics. The Clery Act requires all colleges and universities that participate in federal
financial aid programs to keep and disclose information about crime on and near their respective campuses. No
personally identifiable information about you is disclosed in the preparation and publishing of Clery Act reports.
The College can act on your complaint if you decide to pursue it at a later date. You may request further action
at any future time, consistent with the institution’s policy. The longer the period of time lapsed from the time of
the incident, the more difficult it will be to obtain information.
You may have protections under Title IX and the Violence Against Women Act (VAWA)/Clery Act. Sexual
harassment, sexual assault, and sexual violence are forms of sex discrimination and therefore violate law and policy.
Retaliation against anyone who participates in a complaint process will result in appropriate sanctions or other
disciplinary action as covered by applicable policies, laws and/or collective bargaining agreements.
You are encouraged to meet with the Title IX Coordinator at any time to discuss your options, concerns
and questions. Please contact Title IX Coordinators via phone or email – give infosheet with contact info. The
Title IX Coordinators are located in Park Center. The Title IX webpage at www.meredith.edu.title-ix outlines
available resources and your rights.
I understand I have the right to a conduct process
(as applicable) that runs concurrently with a
criminal justice investigation and proceeding, except
for temporary delays as requested by external
municipal entities while law enforcement gathers
evidence.
I understand I can change my decision regarding the
above listed services at any time. If I change my
decision, I will contact Campus Police, a Title IX
Coordinator, or the campus resource directly. I have
been advised of the options and resources available to
me and the information contained on this form.
Reporting Individual’s Initials:
Date:
2020 Meredith College
I have advised the reporting individual on options,
resources and interim measures available. I have also
provided written information including a list of
community and campus resources and other brochures
and handouts as appropriate.
Print Name & Signature (College Official):
___________________________________________
___________________________________________
Date: ______________________________
Make Three Copies
Original: The Title IX Coordinator.
Copy: Copy for office records.
Complainant: Provide a copy upon request.
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INTAKE FORM TITLE IX REPORT INFORMATION (Meredith College)

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Completed 1 February 2021

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