Title IX Complaint Form
Policy AC: Non-Discrimination
Michael Koury Title IX Coordinator mkoury@cobreschools.org (575) 495-0982
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Email *
Date Filed: *
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Name of complainant (alleged victim):
*
Birth Date of complainant:
*
MM
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DD
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YYYY
Organization (school/department):
*
Organization's Phone Number:
*
Who is filing the complaint?
*
Summary of alleged unlawful discrimination or harassment:
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Name(s) of individual(s) allegedly engaging in prohibited conduct
(Respondent/s)
*
Date(s) alleged prohibited conduct occurred:
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Name(s) of witness(es) to alleged prohibited conduct:
*
If others are affected by the possible unlawful discrimination or
harassment, please give the names:
*
Was CYFD or/and Bayard Police Department contacted? If so, add the case number/s.
*
Actions taken:
*
Electronic Signature of Person Receiving Complaint
*
Date
*
MM
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DD
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