TITLE%IX%
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9!|!P a g e !
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Please!provide!options!for!consideration.!
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Other!information !and/or!evidence:! Yes! □! No! □!
Please!add!additional!important!information!not!covered!by!other !parts!of!this!form!on!a!separate!sheet.!
Where#to#take#your#co ncern#or#issue:#
If!you!did!not!reach!a!resolution!at!th e!informal!stage,!direct!your!concern!or!issue!as!follows:!
Classroom!or!course!related!
! ! ! First!Step:! 1.!Talk!to!professo r!involved !if!iss ue!is!more!!! ! !
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! ! !!!!If!no!resolution: ! 2.!D epartmen t!Chair!
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Harassm ent!and/o r!Discrimi natio n!! Dr.!Karen!Panunto!Ext.!2511;!Classroom!based,!(Title!IX !Coordinator)!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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Hou sing/ Student!Rights! &!Re sponsibilit ies! Nate!Biondi,!Ext.!2458;!Asst.!Director!for!Housi ng;!Student!Af fairs!
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Campus!Activities/Program!Related! Elana!Baukman!Ext.!2567;!Director!of!Campus!Life!
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Student!Conduct‐!i ncluding!Sexua l!!!!!!!!!!!!!!!!!Melissa!Elliott!Ext.! 2586;!Asst.!Dean!of!Stud ents,!(Title!IX!Coordinator)!
Assault/Sexual!Harassment! ! !
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Health!Concerns! ! ! ! Jill!Maser! Ext.!2521;!Director!of!Wellness!
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Hostile!Work!Environm ent! ! Dana!Huber!Ex t.!2333;!Human!Res ource!Manager,!!!
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Medical! College!Withdrawal!!!!!!!!!!!!!!!!!!!!!!!!!!!!Brian!Belcher!Ext.!2739; Coordinator of Disability Support,!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !(Title!IX!Coordinator)!
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Other!or!General!issues! ! ! !As!a!starting!point!con tact!Student!Affairs,!CC!125!E xt.!2506!
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By!signing!belo w,!I!acknowledge!that!t he!statements!made!herein!have!been!truthful!and!to!the!best!
of!my!knowled ge.!
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Your!signature !_____________________________ ____!! Date!____________ _______________!
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Resolution:!
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Administrator!–!Print!and!sign!name! ! ! ! ! Date!
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