Fillable TITLE IX INCIDENT REPORTING FORM (Hawaii Community College)

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TITLE IX INCIDENT REPORTING FORM (Hawaii Community College)

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09/02/2016 1
TITLE IX INCIDENT REPORTING FORM
Hawai‘i Community College is fully committed to providing an atmosphere free from
discrimination on the basis of race, sex, gender, sexual orientation, age, religion, color, national
origin, ancestry, disability, domestic violence, marital status, arrest and court record, and veteran
status.
Acts of sex or gender based discrimination will be addressed consistent with the University of
Hawai‘i Board of Regents’ policies, as well as state and federal law. If you or someone you know
has experienced sex or gender-based discrimination at Hawai‘i Community College, please
complete this Title IX Incident Reporting form. The purpose of the form is to understand the basis
of your report. Upon completing the form, submit it and all other relevant information to the
Title IX Coordinator. This Title IX Incident Reporting form is in compliance with UH Policy
EP 1.204, Title IX, and VAWA.
Reporting to Hawai‘i Community College is completely separate and distinct from the criminal
reporting process. Individuals, who wish to report allegations to law enforcement or initiate civil
proceedings, are encouraged to do so at any time.
I wish to remain anonymous. I understand that under Title IX, Hawai‘i Community College
may be required to investigate and take reasonable action in response to the information I provide
on this form. I also understand that this may limit Hawai‘i Community College’s ability to
respond to my complaint.
OFFICIAL USE ONLY:
Title IX Coordinator (T9C)
Tel.: (808) 934-
2765
Mari Chang
Title IX Deputy Coordinator for
Employees (DET9C)
Location: MC 397-4
Tel.: (808) 934-2525
Email: changm@hawaii.edu
Kate De Soto, LCSW
Confidential Resource
Mental Health Therapist
Mental Wellness & Personal Development
Location: Bldg 383 Rm. 105
Tel.: (808) 934-2706
Email: kdesoto@hawaii.edu
DATE OF FILING: _______________________________________________________________
Title IX COORDINATOR: _________________________________________________________
Mari Giel
Title IX Deputy Coordinator for
Students (DET9C)
Location: MC 388-106
Tel.: (808) 934-2725
Email: marigiel@hawaii.edu
2
TITLE IX INCIDENT REPORTING FORM
Name:____________________________________________________________________________________
Department:_______________________________________________________________________________
Title:_____________________________________________________________________________________
Phone:____________________________________________________________________________________
Email:____________________________________________________________________________________
INFORMATION ABOUT THE REPORTER
Name:
Address:
Phone:
E-Mail:
UH ID# or Username (if applicable):
INFORMATION ABOUT THE VICTIM/WITNESS (If not same as above)
Name:
Address:
Phone:
E-Mail:
UH ID# or Username (if applicable):
GENERAL INCIDENT INFORMATION
Date(s) of Alleged Incident(s):___________________________________________________________________
Location(s) of Alleged Incident(s):________________________________________________________________
Parties Involved:______________________________________________________________________________
H
awCC Faculty/Staff to complete if/when assisting the reporter
05/22/2016 3
Please describe in detail the incident you are reporting; include names of all parties involved,
date(s) and time(s) of the incident(s), location (s), and other pertinent information (space is not
limited to this form).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
State the resolution you are seeking (space is not limited to this form):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
List and attach any evidence, documents, names of witnesses, and/or additional materials you
have to support your report of events (space is not limited to this form):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
05/22/2016 4
Discrimination is defined as a treatment or consideration of, or making a distinction in favor of or
against, a person or thing based on the group, class, or category to which that person or thing
belongs. Please indicate any sex or gender-based discrimination, and/or additional criteria, listed
below were involved in the alleged incident(s). Check all that apply:
Ancestry
Religion
Age
Sex
Arrest/Court record
Sexual orientation
Color
Veteran status
Disability
Other
If you selected “Other,” please explain below:
REPORTING PERSON ACKNOWLEDGEMENT:
I affirm that to the best of my ability and knowledge, the information provided in this form is accurate and the
ev
ents/circumstances are as I described
.
I understand that submission of this Title IX Incident Report will not lead to retaliatory action against me.
University policy and state and federal law prohibit retaliation. Retaliation is defined as adverse treatment,
in
timidation, threats, coercion, or discrimination against an individual for the purpose of interfering with any
nondiscrimination rights s/he may have under University EEO/AA policies or because s/he has made an inform
al
o
r formal complaint, served as a witness, or participated in any manner in a complaint resolution process or
investigation.” (from UH Administrative Procedures A9.920) A complaint of retaliation will result in a separate
in
vestigation and may result in disciplinary action as appropriate.
I understand this form, including any attachments, will be sent to the Title IX Coordinator.
To safeguard individual privacy, dissemination of information obtained during this report will only be
reported to “individuals actually involved in the informal or formal proceedings. However, complet
e
conf
identiality cannot be maintained in the process of handling informal and formal complaints. Certain
information may be disclosed to appropriate administrators, the Respondent, and witnesses, among others,
in order to conduct fact finding, institute remedial action, or informally resolve a complaint. Also, certain
information may be disclosed if by law, rule, regulation, or order of a court of competent jurisdiction.”
(from UH Administrative Procedures A9.920). For example, in the event that a grievance is filed relating
to this investigation, the information you provide is subject to being released or subpoenaed by the parties
involved.
Hawai‘i Community College understands that just because information is reported that could describe or
constitute a violation of policy or employee misconduct, it does not necessarily mean that such a violation
or act of misconduct has occurred. That is the purpose of conducting this investigation. Information you
provide in this report will be reviewed along with other witness statements to determine whether reported
behavior actually constitutes a violation of policy or act of misconduct. In the event the Hawai‘i
Community College deems it warranted, this investigation could lead to disciplinary action as appropriate.
SIG
NATURE:__________________________________ DATE:___________________
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Completed 25 July 2020

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