Consent for Release of Records to the Marshall University Title IX Office

This form allows a student to provide written, FERPA‑compliant consent for the release of records and related information to the Marshall University Title IX Office for use in a Title IX–related matter involving the student. Completion of this form authorizes the sharing of records, appointment history, and relevant information directly with the Title IX Coordinator and designated Title IX personnel for the sole purpose of assisting with the student’s participation in the Title IX process. Submission of this consent is voluntary and may be revoked at any time.

Please use this form to provide consent for Marshall University’s Title IX Office to request and receive records or information relevant to your Title IX matter.

Information Authorized for Release

1. Records (all documents including any reports generated) related to my care 2. Notes, as permitted by FERPA 3. Appointment history and attendance information 4. Any information relevant to my participation in a Title IX matter 5. Verbal communication between staff and the Title IX Office regarding the above

Purpose of Disclosure

This release authorizes the Title IX Office to access this information solely for use in a Title IX-related matter involving me. No other use or disclosure is permitted under this authorization.

My Rights

1. This consent is voluntary, and I may refuse to sign it without affecting my access to services or opportunities at Marshall University. 2. I may revoke this authorization at any time by notifying the Title IX Office in writing, except to the extent that information has already been obtained or relied upon. 3. I understand that this consent authorizes the release of records to the Marshall University Title IX Office, and that the Title IX Office may share relevant information with other University officials, including Athletics, the Office of General Counsel, Student Conduct, or other appropriate administrators, only when necessary for institutional decision‑making, including decisions related to enrollment, eligibility, safety, potential sanctions, recommendations, or other legitimate University purposes. 4. This authorization will expire one (1) year from the date of consent, unless I revoke it sooner in writing.

Information about You

Your Name(Required)

First Middle Last

Student ID Number(Required)

Provide your Marshall University ID Number - If you do not have a MUID, just list Not Applicable (N/A).

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Entities to Contact for Records(Required)

List all entities that have your records.

Your Name(Required)

First Middle Last

CAPTCHA

Thank you for taking the time to fill out the Consent for Release of Records to the Marshall University Title IX Office Form.

Important Reminder: Online Reporting Strongly Preferred

Title IX Reporting - Online Submissions PREFERRED:

The Title IX Office prefers the submission of Title IX report through the online reporting system. It is preferred that all Title IX reports be submitted through our secure online form. This centralized process helps us review reports promptly, triage concerns efficiently, and ensure consistent and equitable responses for our campus community.

In‑person, email, and phone submissions are accepted on a limited basis as reporting methods for Title IX incidents. Those conversations may still occur for support purposes, but they do not constitute an official Title IX report.

Submit an Online Title IX Report

Please note: Due to staff availability, it may take up to five business days for your report to be reviewed.

If You Are in Crisis

Call 911 or contact the Marshall University Counseling Center for immediate support:
Prichard Hall, First Floor
304-696-3111
Marshall University Counseling

We appreciate your understanding and remain committed to supporting a safe, respectful, and inclusive campus environment.