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/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

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Title IX Complaint and Intake Form

The purpose of this form is to provide information to the Title IX Coordinator regarding concerns of sex-based discrimination, sexual harassment or sexual violence so that any further misconduct can be prevented, supportive measures can be provided as needed, and additional action, in accordance with Title IX Resolution Procedures, can be taken. If you have experienced any form of sexual violence, harassment or discrimination, the most important things are getting to a safe place and taking care of yourself. Realize that what happened to you is not your fault and that you are in control of what happens next. Telling someone is a brave act, but there may be reasons why you might not feel comfortable sharing with other people. At the same time there are many benefits to telling someone what happened and for this reason we encourage you to inform us on any incident. You can use this form to report an incident or you may contact the Title IX Coordinator, Natalie, Holick, at 913 588-8011 or nholick@kumc.edu.

Date of this report (mm/dd/yyyy):

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Has this incident been reported to the KU Police Department?

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Yes

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Name of the Complainant:

Is the complainant a:

Student

Employee

Visitor

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ID Number:

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Department or Program:

Complainant Daytime Phone:

Complainant Evening Phone:

Complainant Address:

Complainant Email Address:

Complainant Preferred Method of Contact:

Phone

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Date of the Incident(s) (mm/dd/yyyy):

Approximate Time(s):

Where did the incident(s) take place (be specific)?

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What type of incident(s) occurred?

Sexual Harassment - unwelcome conduct of a sexual nature and can include unwelcome sexual advances, requests for sexual favors, and other verbal, nonverbal, or physical conduct of a sexual nature, such as assault or acts of sexual violence. Students or employees of any sex can be victims of sexual harassment and the harasser and the victim can be of the same sex.

Quid Pro Quo - an employee of the university conditions the provisioning of an aid, benefit, or service of the University on an individual's participation in unwelcome sexual contact.

Hostile Work Environment - unwelcome conduct (including physical, visual, audible, and electronic conduct) determined by a reasonable person to be so severe, pervasive, and objectively offensive that it effectively denies a person access to the University's education programs and activities.

Dating Violence - violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim. The existence of such a relationship shall be determined based on a consideration of the length of the relationship, the type of relationship, and the frequency of interaction between the persons involved in the relationship.

Domestic Violence - a form of sexual violence and is abuse committed against someone who is a current or former spouse, current or former cohabitant, someone with whom the abuser has a child, someone with whom the abuser has or had a dating or engagement relationship, or someone similarly situated under Kansas domestic or family violence law.

Forcible Sex Offense - Any sexual act directed against another person, without the consent of the victim including instances where the victim is incapable of giving consent.

Stalking - engaging in a course of conduct directed at a specific person that would cause a reasonable person to 1) fear for their safety or the safety of others, or 2) suffer substantial emotional distress. Course of conduct means two or more acts, including, but not limited to, acts in which the stalker directly, indirectly, or through third parties by any action, method, device, or means, follows monitors, observes, surveils, threatens, or communicates to or about a person, or interferes with a person's property. Reasonable Person means a reasonable person under similar circumstances and with similar identities to the victim. Substantial emotional distress means significant mental suffering or anguish that may, but does not necessarily, require medical or other professional treatment or counseling.

Other - please describe:

Other - please describe

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Describe the incident(s), including dates, places, witnesses, and any documentation:

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Please use this field to upload documentation.

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Please use this field to upload documentation.

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Please use this field to upload documentation.

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Name of the Respondent:

Is the Respondent a:

Student

Employee

Visitor

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Respondent Student or Employee ID Number:

Respondent Department:

Respondent Daytime Phone:

Respondent Evening Phone:

Respondent Address:

Respondent Email Address:

Respondent Preferred Method of Contact if Known:

Phone

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Person 1:

Name:

Date Notified:

Student or Employee ID Number:

Title or Department:

Daytime Phone:

Evening Phone:

Address:

Email Address:

Person 2:

Name:

Date Notified:

Student or Employee ID Number:

Title or Department:

Daytime Phone:

Evening Phone:

Address:

Email Address:

Name of the Person Completing this Form:

Student or Employee ID Number:

Department:

Daytime Phone:

Evening Phone:

Address:

Email Address:

*While optional, you are encouraged to provide this information to assist the Title IX Investigator's ability to conduct a thorough and complete investigation.

Confidentiality

The Title XI Coordinator will make reasonable and appropriate efforts to preserve the Respondent's and Complainant's privacy and protect the confidentiality of information. Should the Complainant request confidentiality the Title IX Coordinator will inform them that KUMC's ability to respond may therefore be limited, but that where feasible, it will take reasonable steps to prevent prohibited conduct and limit its effects. The Title IX Coordinator will also inform the Complainant that it is not always possible to provide confidentiality and that KUMC's decision to share information with others is subject to other considerations. KUMC is required by law to report certain types of reported sexual misconduct in its annual crime statistics report. Names and other identifying details of the incident are not made public in the annual crime report. KUMC is also required by law under certain circumstances to report any incident which might be classified as a violent crime, hate crime, or sexual assault to law enforcement. While KUMC strongly encourages and will assist the Complainant in filing a report with the Police or other trauma services, ultimately it is up to the Complainant whether or not to take this action. Except if required by governmental agencies, KUMC will not disclose a victim's identity unless the victim consents to being identified after being informed of their right to have identifying information withheld. If a victim does not consent to disclosing their identity, the alleged perpetrator's identity will not be disclosed either, unless required by governmental authorities.

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