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