Title IX Report

Background Information

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Your full name:

Your relationship to Valencia:

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(Student, Faculty, Staff, Other)

Your phone number:

Your email address:

Email address must be of a valid format.

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(Faculty/Staff/Students please use your Valencia Atlas email address)

Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Specific location:

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(room, building, parking lot, etc.)

Involved Parties

Please include information about the following parties if known:

Complainant - An individual who is alleged to be the victim of prohibited conduct.
Respondent - An individual who is alleged to have engaged in prohibited conduct.
Reporting party - A third party who makes the College aware of prohibited conduct.
Witness - An individual who is alleged to have witnessed prohibited conduct.

Name or Organization

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VID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Alleged Behavior

Detailed description of alleged misconduct(Required) This field is required.

Please review and CHOOSE ONE of the options below:(Required)

By selecting this option, I certify that I am the Complainant as defined in College Policy 6Hx28:2-01-Discrimination, Harassment and Related Misconduct, and acknowledge my digital signature confirming that I am the Complainant in this report. I am requesting that Valencia College take appropriate action to respond to this complaint. This includes, but is not limited to, notifying the Respondent of the allegations, and based on US DOE Title IX Regulations, and this also includes notifying the Respondent of my identity. I acknowledge that because of submission of this formal complaint that I will be contacted by a representative of the College who will provide me with additional details regarding supportive measures as applicable as well as additional information regarding the College’s process as outlined in 6Hx28:2-01-Discrimination, Harassment and Related Misconduct. I also acknowledge that the College’s ability to effectively respond to the allegations may be impacted by my decision to not participate in any possible investigation, Title IX Hearing, or informal resolution options. I agree and I am the Complainant By selecting this option, I acknowledge that I am not the Complainant as defined in College Policy 6Hx28:2-01-Discrimination, Harassment and Related Misconduct. I am reporting to the college conduct that I have witnessed or have knowledge of occurring. I understand that my report does not constitute a formal complaint and am aware that the college will proceed in its review process which may include contacting the complainant and/or respondent listed in the report. I also acknowledge that the College’s ability to effectively respond to the allegations may be impacted should the Complainant decide not to participate in any possible investigation, Title IX Hearing, or informal resolution options. I agree and I am NOT the Complainant

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Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Alleged Behavior

Supporting Documentation

Submission