Harassment Incident Report Form

1. Harassment Incident Report Form This form is to be used as the first report of an alleged harassment incident. The person completing this form should submit it immediately to the Title IX Coordinator Dr. Neil Nuttall in order to activate a thorough and prompt investigation. Information regarding an alleged harassment incident shall be kept confidential to every extent possible. The individual reporting the incident shall not discuss this information outside of the investigative process. If a report is completed by someone other than the victim, “reported by” fields must be complete. Additional information may be attached to this form. Harassment is defined as conduct and/or verbal action which is sufficiently severe, persistent or pervasive to limit either an individual’s ability to participate in or benefit from the educational program, or to create a hostile or abusive environment for students, faculty or staff. Harassment includes but is not limited to incitement of or threat of violence; epithets referring to race, gender, disability, age, national origin, religion or sexual orientation; and/or physical conduct by an employee, student, or third party which is unwelcome, hostile, or intimidating. Harassment also includes other forms of conduct and/or verbal actions that are derogatory, hostile, intimidating, threatening, “bullying,” humiliating or violent . Any form of harassment is a violation of NCMC’s Sexual Harassment Policy, the Student Code of Conduct and The College Non-Discrimination Policy. Reported By: Date and Time Reported: Date of Incident: Time of Incident: Complainant Name: Alleged Harasser(s): Location where Incident Occurred: Victim Type:Student Employee Guest AM or PM AM or PM Type of Harassment Age Marital Status Race Religion Disability National Origin Gender Physical Sexual Genetics Attributes Brief Description of Incident: (Attach additional information if necessary) List Names of Any Witnesses to the Incident: Additional Comments: Reported By: Date: Victim Signature: Date: Received By: Date: Dr. Neil Nuttall, NCMC President and Title IX Coordinator