Panola College Title IX Incident Report

Panola College Title IX Incident Report
This form is designed to report a violation of Title IX. We appreciate any contact information you are willing to provide. You are welcome to remain anonymous if desired.

By completing this form, you acknowledge that you are initiating a complaint which will be investigated per Panola College policy. You certify that the following information is accurate to the best of your knowledge. Please contact the local authorities if you need immediate assistance by dialing 911 or calling Campus Police at 903-693-1111.
Contact information

You may leave this section blank to submit an anonymous report.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am a

StudentEmployeeOther
Name of those involved in the incident:*
This report is related to (select all that apply)*

AgeColorDisabilityNational OriginRaceRetaliation to a filed complaintSex
Description of the Incident (List dates/times/location and what occurred):*
List any witnesses or person that you believe could provide information regarding your complaint. (Include contact information for those individuals, if possible)
If you have any documentation of the incident (e-mails, letters, pictures, etc.), you may upload those here or turn those into our Title IX coordinator, Jeremy Dorman, Martha Miller Administration Building – Office of Human Resources, 903-693-2021 or hr@panola.edu.

Cancelof
What action would you like Panola College to take following the receipt of this complaint?*
Should be Empty:

Panola College Title IX Incident Report

Contact information