Submit a Title IX Notice Form

Students who require accommodations to file a complaint regarding Title IX, contact:

Title IX Coordinator
Aspen Monsma
Student Access Coordinator/Section 504 Coordinator
304.260.4380 ext. 2117
amonsma@blueridgectc.edu

Students who require accommodations to file a complaint regarding Section 504 or to file a complaint, contact:

Student Access Coordinator/Section 504 Coordinator
Aspen Monsma
304.260.4380 ext. 2117
amonsma@blueridgectc.edu

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Incident*

Date

Complainant Status*

Accused Status*

What is the name of the person accused? *

Where did the incident take place?*

How often does this situation occur? (once, weekly, daily, etc.)*

Please list any witnesses or observers to this event:

Do you know anyone else who has had the same experience as you?

Is there anyone else who has relevant information? If so, who?

Is there any written documentation to support your allegations?

How would you like to see this situation resolved?*

Please describe the incident with as much information as possible?*

I assert that the information I have included in this form is accurate to the best of my knowledge. I understand that this form will be provided to the Title IX Coordinator, who will review the information provided and determine whether further action is needed in order to ensure my safety and the safety of the College community. I understand that if I have chosen to file this report anonymously, the College's ability to respond will be severely limited. I further understand that, if I have included my name and contact information, the Title IX Coordinator may contact me for further information.

Yes