Fillable Referral Form: Discrimination, Harassment, Gender-Based Misconduct (Mitchell Community College)

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Referral Form: Discrimination, Harassment, Gender-Based Misconduct (Mitchell Community College)

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MCC-496b Equal Opportunity College Rev. 01/19
Referral Form: Discrimination, Harassment,
Gender-Based Misconduct
Your Full Name ___________________________________________________ Position/Title (if any) _______________________________________
Phone # ___________________________________________________________ Email _______________________________________________________
Reason for this referral (Required) _______________________________________________________________________________________________
Select your role ___________________________________________________
Date of Occurrence (if known—Required) ___________________________________________ Time of Incident ________________________
Location of Occurrence (Required) _______________________________________________________________________________________________
OR Other __________________________________________________________________________________________________________________
Involved Parties/Witnesses
Name of Individual or Organization ______________________________________________________________________________________________
Gender __________________________________________
Phone # ___________________________________________________________ Email _______________________________________________________
Name of Individual or Organization ______________________________________________________________________________________________
Gender __________________________________________
Phone # ___________________________________________________________ Email _______________________________________________________
Please Choose
Please Choose
Please Choose
Please Choose
Please Choose
MCC-496b 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)
Please indicate other departments that have been notified (Optional)
Rape Crisis/Anti-Violence Support Center
Counseling/Advising Office
Campus Security
Other ___________________________________________________________________________________________________________________________
Supporting 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.
Referrer Affiliation
Are you, the referrer, a student, faculty, or staff member? Yes No
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Referral Form: Discrimination, Harassment, Gender-Based Misconduct (Mitchell Community College)

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Completed 26 July 2020

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