MCC-496 An Equal Opportunity College Rev. 01/19
Referral Form: Discrimination, Harassment,
Gender-Based Misconduct
Yo
ur Full Name ___________________________________________________ Position/Title (if any) _______________________________________
Phone # ___________________________________________________________ Email _______________________________________________________
Reason for this referral (Required)
Please choose Witness Referral Complainant Third-party
Date of Occurrence (if knownRequired) ___________________________________________ Time of Incident ________________________
Location of Occurrence (Required)
On-campus Public Property Off-campus Other ____________________________________
Specific Location __________________________________________________________________________________________________________________
In
volved Parties/Witnesses
Name of Individual or Organization ______________________________________________________________________________________________
Gender Male Female
Phone # ___________________________________________________________ Email _______________________________________________________
Nam
e of Individual or Organization ______________________________________________________________________________________________
Gender Male Female
Phone # ___________________________________________________________ Email _______________________________________________________
1/23/19
MCC-496 An Equal Opportunity College Rev. 01/19
Narrative Information/Notifications
Please provide a narrative of the incident. Be sure to provide as much information as possible about the incident
(Required)
Ple
ase indicate other departments that have been notified (Optional)
Rape Crisis/Anti-Violence Support Center
Counseling/Advising Office
Campus Security
Other ___________________________________________________________________________________________________________________________
Su
pporting Documentation
Attachments must be send as Microsoft Word or Adobe PDF files. 1GB maximum total size. Attachments required time to
upload, so please be patient after submitting this form.
Re
ferrer Affiliation
Are you, the referrer, a student, faculty, or staff member? Yes No
test
SUBMIT
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