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Discrimination and Harassment Incident Form


The purpose of this form is to report alleged incidents of unlawful discrimination and harassment based on a persons protected class status of race, color, religion, sex, national origin, age, disability, veteran status, genetic information, sexual orientation, gender identity, and pregnancy.  In addition to sex based discrimination, federal law requires the University to also address conduct described under the Title IX Amendment of 1964, which includes; rape, sexual assault, partner violence, stalking, sexual harassment, or sexual discrimination, including gender-based harassment, intimate partner violence, and stalking. 

This form can be utilized by students, faculty or staff wishing to file an incident report on their own behalf or on the behalf of another University of Southern Indiana member.

Filing this report does not constitute filing a formal complaint.

Please note that submissions using this form are not be reviewed outside of normal business hours.

If there is immediate risk to health or safety, please contact Public Safety at (812) 492-7777 or 911 if you are off campus.

Background Information

Please note that as Responsible Employees all faculty, staff , and administrators are expected to report any disclosures that involve allegations of in violation of the Sexual Harassment Policy (F.1). Exceptions are made for Confidential Employees, who are required by law to work in a confidential capacity (counselors, medical providers and clergy).

 
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You may choose to report anonymously unless you are a Responsible Employee.
Email address must be of a valid format.
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What type of affiliation does the Impacted Party have to USI?
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approximate the date if unknown
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Approximate time (if known)
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Where did the incident happen?
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Address if known

Person(s) Involved in the Incident

Please provide the names of the persons involved. If the survivor (victim) has requested confidentiality and you are a Confidential Reporting Resource (Counseling, Health Center), then please type "Anonymous." All others must report all known details, including names for incidents of Sexual Harassment. If the alleged is unknown, please type "Unknown."

Involved party 1

Incident information

Please provide a narrative and information below. Provide as much information as possible.

Type of incident? Check all that apply.(Required)
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Do you have any reason to believe this incident represents an immediate threat of harm or danger to the targeted individual or other members of the community?
You must make at least one selection.
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Was a weapon involved?(Required)
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Please indicate other departments that have been notified. Check all that apply.
You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission