Title IX Reporting Form
This form should be utilized to provide RCBC with information regarding an incident that violates Title IX. Any reports made through this form will initiate a formal review within the Title IX office. Details regarding reporting, investigations, and hearings are provided on the Title IX website available at rcbc.edu/diversity.

As detailed in the procedures, the college will support all efforts to maintain privacy regarding incidents reported through this form, but this form is not considered confidential reporting. If you prefer confidential reporting, please see one of the options below:

-- Students can schedule online with the Student Support Counselor at http://www.rcbc.edu/counseling/request-form or contact 856.222.931, ext 1582. Off campus confidential reporting options are available in the online procedures. Please do not submit requests for Confidential Reporting through this form. If you need assistance with next steps, please contact the Student Support Office.

-- Employees can request Carebridge resources through Human Resources for Confidential Reporting. Additional off campus confidential reporting options are available in the online procedures. Please do not submit requests for Confidential Reporting through this form. If you need confidential assistance, please contact Human Resources for direct contact information for Carebridge.

Unless there is a threat to the campus community, investigations are not initiated on confidential reports through these stated resources unless the victim requests action.

A copy of this report will be sent to

Catherine R. Briggs, Ed.D.
Dean of Student Success / Title IX Coordinator
856.242.5391
cbriggs@rcbc.edu

Please provide detailed information regarding the incident you are reporting.
What is your first name? *
Your answer
What is your last name? *
Your answer
What is your role at the college? *
What is your role in reporting this incident? *
What is your preferred phone number? *
Your answer
What is your email address? *
Your answer
What is the nature of this report? *
Where did this incident occur? *
When did this incident occur? *
MM
/
DD
/
YYYY
What time did this incident occur?
Time
:
What is the specific location of the incident? *
Your answer
Please provide information on the individuals directly involved in the incident, including name, gender, phone number, and email. *
Your answer
Please provide information on the individuals who witnessed the incident, including name, gender, phone number, and email. *
Your answer
Please provide a detailed description of the incident / concern/ If you have listed an individual as an involved person, they should appear at least once in the narrative below. If you have concerns for the immediate health and safety of yourself or others, please call 911. *
Your answer
Did you speak with a confidential resource on campus regarding this incident (on campus confidential resources only include a Student Support Counselor) *
Did you speak with any law enforcement agency about this incident? *
If you did speak to law enforcement, please provide the township information below. *
Your answer
Did you seek medical attention for this incident? *
How would you like to receive follow up information for this incident? *
Do you have supporting documentation for this reported incident in the form of photographs, text messages, emails, social media communication or other documentation? If you answer "yes" to this question, you will be contacted by the Title IX office for submission of any related items. *
Submit
Never submit passwords through Google Forms.
This form was created inside of Rowan College at Burlington County. Report Abuse