Title IX Report Form

***If this is an emergency, please call 911 or Campus Police at 410-386-8123. If you have a concern about a Carroll Community College student, staff, or visitor related to sexual misconduct or gender based discrimination, complete this form. If you have any questions, contact the Title IX Coordinator, Robert Brown, TitleIX@carrollcc.edu, Phone: 410-386-8224, Office: A117. When completing this form, include your name, and contact information. Provide as much detailed information regarding concern or incident as possible. We encourage you to include your contact information so that we may follow up with you. Please note this is not a confidential reporting system.

Name(Required)

First Last

Phone(Required)

Email(Required)

Date(s) and Time(s) of Incident(Required)

Location of Incident(Required)

Involved Student Name(s)

Detailed Description of Incident(Required)

Campus Alert

Title IX Report Form