General Category of Report/Disclosure:
Sexual Harassment Sexual Assault Stalking Intimate Partner Violence
Domestic Violence Dating Violence Other:______________________________________
Description of the Incident:
Please be as specific as possible and include facts shared by the complainant, and names of witnesses, if
Has the reporting party reported the incident to the police? Have they filed an internal complaint? Is
victim working with an outside agency? Have you shared this information with any other offices?
This report/disclosure should be returned to Ricky Barrett, Counselor Primary Title IX, Founders Hall, Rm.
121, RBarrett@Mxcc.edu, or Anastasia Pych, Human Resources Director and Secondary Title IX
Coordinator, Founders Hall, Rm. 115, APych@Mxcc.edu, and Carolyn Innocenzi, Evening Coordinator &
Administrator: MxCC@Platt CInnocenzi@mxcc.edu Founders Hall, Room 108 and Platt High School.