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Person Filing This Form (Please check all that apply):
  • Survivor/Victim
  • Student
  • Faculty/Staff/Administrator
  • Friend/Acquaintance/Family Member
  • Alumna
  • Other (Please specify):
Survivor/Victim’s Affiliation to Mount Mary (Please check all that apply):
  • Student
  • Faculty
  • Staff
  • Administrator
  • Alumna
  • Visitor
  • Other (please specify):
Perpetrator’s Affiliation to Mount Mary (Please check all that apply):
  • Student
  • Faculty
  • Staff
  • Administrator
  • Alumna
  • Visitor
  • Other (please specify):
Type of Incident (Please check all that apply). Description of some categories to the right.
  • Sexual Harassment
  • Non-Consensual Sexual Contact
  • Non-Consensual Sexual Intercourse
  • Sexual Exploitation
  • Other (please specify below):
I would like to be contacted by:
  • Dean for Student Affairs (Title IX Coordinator)
  • Director of Human Resources (Title IX Coordinator)
  • Director of Public Safety
  • Counseling Center
  • Other (please specify):