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Harassment (Sexual Misconduct) and Discrimination Complaint Form

If you need to report an emergency or are reporting an incident that poses an imminent risk of harm, call the Department of Public Safety by dialing 9-1-1. Please know that completing this report does not substitute contacting the Department of Public Safety or other emergency personnel.

Prior to completing this form, please consider reviewing the Arkansas Tech University (ATU) Equal Opportunity, Harassment (Sexual Misconduct), and Nondiscrimination Policy and Procedures at https://www.atu.edu/titleix/policy.php.

This form is designed to provide students, staff, faculty, vendors, visitors, or others with an on-line method to report specific information related to an alleged incident(s) of discrimination, harassment (including sexual misconduct), or retaliation. When submitting this report, please include as many details as possible including name(s) and contact information.

Reporting carries no obligation to initiate a formal response. ATU respects Complainant requests to dismiss complaints unless there is a compelling threat to health and/or safety. Please be aware that inclusion of personally identifying information when an incident indicates a potential health and/or safety concern, may serve as notice to ATU for the purpose of initiating an investigation.

Anonymous reports are accepted via this reporting mechanism but can give rise to a need to investigate. Please note that submitting the report anonymously may greatly limit ATU’s ability to address your concern. ATU tries to provide supportive measures to all Complainants, which is impossible with an anonymous report.

Upon receipt of this report, the appropriate ATU administrator will review the matter and take proper steps to investigate, stop, prevent, and remedy the prohibited conduct in accordance with ATU policies.

To speak with a counselor in confidence regarding an incident, students may contact the ATU Health and Wellness Center at 479-968-0329 to schedule an appointment.

ATU prohibits retaliation of any kind against persons reporting misconduct or any person’s participation in the complaint or investigation process.

If you would like assistance in completing this form, please contact Amy Pennington, Associate Vice President for Student Affairs/Dean of Students & Title IX Coordinator, 479-968-0407, apennington@atu.edu.

Please note that this form may not be reviewed outside of normal business hours.

Background Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide. For non-students, please list a Drivers License number in the block labeled T Number if available.

Name or Organization

Select Role

T Number

DOB (YYYY-MM-DD)

Phone number

Email address

Gender

Questions

What is the nature of this report?(Required)

Dating Violence Discrimination Domestic Violence Retaliation Sexual Assault Sexual Exploitation Sexual Harassment Stalking Other

You must make at least one selection.

Please provide a description of the incident:(Required) This field is required.

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.