Request for Mutual No Contact Order Form

Request for Mutual No Contact Order

This is the Request for Mutual No Contact Order Form to be submitted to be considered by the Title IX Office.

Request for Mutual No Contact Order Form

A party may a Mutual No Contact Order as a supportive measure without proceeding with the formal process. The Mutual No Contact Order will be written as narrow as possible to reduce communication between the parties while not being punitive or disciplinary along with limiting the impact to education programs or activities for either party. A Mutual No Contact Order will have an expiration date. A party may commence the request by submitting their request to the Title IX Coordinator. The Request should set forth: 1) What are the names of the individuals involved in the request, 2) How long are you requesting the Mutual No Contact Order for, 3) What is/are the reason(s) for the request, 4) What fact(s) support the request, and 5) Any specific request involving shared classes, work places, etc. Please be aware that the other party also has the right to ask for an extension, dismissal, or modification of a Mutual No Contact Order as well as appealing the issuance of the Mutual No Contact Order. Additionally, the determination of this request is not subject to the same grievance process as making a determination regarding responsibility under the Title IX policy.

Name of Person Requesting Mutual No Contact Order:(Required)

First Last

Email address of Person Requesting Mutual No Contact Order:(Required)

Enter Email Confirm Email

Name of the Individual Against Whom the Mutual No Contact Order is Requested:(Required)

First Last

Duration of the Requested Mutual No Contact Order:(Required)

You must select one.

four (4) months

six (6) months

one (1) year

What are the reasons for the request? Please provide specific, factual details.(Required)

What facts support the request? Please provide specific, factual details. You can note the information was provide above.(Required)

If applicable, are there any specific requests regarding shared classes, workplaces, or similar situations? [Please keep in mind the following examples: Some classes may only have one section, so limiting proximity or group work in those classes may be necessary. If one party works on campus in a position that requires interaction, such as at a register, they may need to engage for service purposes but should avoid further interaction. Additionally, one party may need to be in the same space due to work obligations. Please provide specific, factual details.]

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Please provide your digital signature below.(Required)

Complainant First Name Complainant Last Name

Verification of Electronic Signature(Required)

I verify that I am the person signing this Request for Mutual No Contact Order Form and it is my name listed above.

Request for Mutual No Contact Order

Request for Mutual No Contact Order Form

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