Case #_____________________
This form may be completed by any member of the West Virginia Northern Community College community who has experienced or otherwise become aware of an incident that may constitute a violation of a school policy. Please complete the form to the best of your ability. https://www.wvncc.edu/other-information/35 Non-Discrimination Statement and associated policies, procedures and forms (including disabilities and Title IX complaint information).
Signature: _________________________________________________________ Date: ______________
Received by: ______________________________________________________ Date: ______________