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:
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
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,
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
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
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
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
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.
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