Sexual Assault, Stalking, or Intimate Partner Violence
Report or Disclosure Form
Please fill this form out and email to: Title IX Coordinator (MX-TitleIX@Mxcc.edu)
Today’s Date_________________________ Date of Report/Disclosure________________________
Complainant, Reporting Victim, or Reporting Third Party - Their Name, Contact Information (phone,
email, address)
Against Whom (Accused/Perpetrator/Suspect - Their Name, Contact Information (phone, email,
address)
Name and Contact Information of Person Who Reported the Incident to You (optional; if different
from the complainant)
The information was shared with me as a:
Disclosure only: The information was shared without a request for investigation and resolution.
I provided resource materials including the contact information of a trained victim advocate and
the College’s Title IX coordinators.
Report: An investigation and action by the College was requested. I provided resource materials
including the contact information of a trained victim advocate and the College’s Title IX
coordinators.
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
available.
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.
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