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Sexual Misconduct or Title IX Complaint Form

Your name:
First Last
Your email address:
Your cell phone number:
Location of incident:*
Date of incident:*
MM slash DD slash YYYY
Time (can be approximate):*

: Hours

Minutes

AM/PM
Please provide a brief description of the incident:*
Name of the alleged victim:
First Last
Gender of the alleged victim:
- Female
- Male
Select the choice that best describes the alleged victim.
- Manna University student
- Faculty or staff
- Non-student, community member
- Visitor
Name of the person responsible:
First Last
Gender of the person responsible:
- Female
- Male
Select the choice that best describes the person responsible:
- Manna University student
- Faculty or staff
- Non-student, community member
- Visitor
Were any other individuals involved? If so, please indicate how many, their names, and their respective gender(s).
Please check the box below to confirm that you understand that all reports will be reviewed. Confidentially is an important value; however, the University has an obligation to interview individuals or review organizations or events that might violate University policy and create an unsafe environment. Filing a false claim is a serious violation of Manna University community standards and will be dealt with diligently.*
I understand, and I pledge that the information submitted is accurate.
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Manna University – 5117 Cliffdale Road Fayetteville, NC 28314 – 910.221.2224

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International Fellowship Of Chaplains

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