Title IX and DHR Reporting Form

Your Information

Please fill out below with your information as a reporter. If you are reporting for yourself, please inlcude your information here and under "Involved Parties." For the purposes of our form, please use "Complainant" for the victim/survivor and "Respondent" for the suspect/perpertrator.

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Full Name and Job Title/Dep't:

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Job title is for employees and student employees.

Student, Employee, Other:

Your phone number:

Your email address:

Email address must be of a valid format.

Mailing Address:

Type of Misconduct(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

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If you do not know the date, please enter today's date and explain below in question #2.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

In this section, please list the Complainant (the person who experienced alleged conduct - if this is yourself, please include your information). Please also include the Respondent (the person accused of misconduct). We also request that you list any individuals who may have observed or witnessed the incident(s) that you described. Please list as much information as you have about each individual (student ID, email address, phone number).

Full Name

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Incident Information

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).(Required) This field is required.

Describe the specific harm resulting from the incident(s). Please be as specific as possible.(Required) This field is required.

What did you or others do to try to resolve the incident/concern? What was the outcome?(Required) This field is required.

Do you have documents to support your claim, i.e. emails, text messages, photographs, or videos? (Please describe). This field is required.

If possible, please describe the outcome(s) you are seeking. Be as specific as possible. If you are submitting this report and are not the Complainant, you can leave this section blank. This field is required.

University Police Case Number (not required). This field is required.

You may elect to have an Advisor present at meeting(s) and/or interview(s), which may be a Confidential Survivor Advocate. If you indicate you will have an Advisor, you are authorizing that individual to accompany you to any meeting(s) and/or interview(s) regarding this matter. The role of the Advisor is limited to observing and consulting with you. Cal Poly Pomona's Confidential Survivor Advocate is Rhonda Dixon. She can be contacted at (909) 869-2196 or survivoradvocacy@cpp.edu. If you plan to be accompanied by an Advisor, please contact OEC at officeofequity@cpp.edu or call at (909) 869-4646. Please provide the name and phone number of the Advisor. This field is required.

I certify that the information given in this incident report is true and correct to the best of my knowledge or belief.(Required)

Yes

You must make at least one selection.

Supporting Documentation

Do you have any documents or electronic communication (including text messages or email)? If so, please attach here. If the files are too larger, please email officeofequity@cpp.edu the link to your files. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Your Information

Involved Parties

Incident Information

Supporting Documentation

Submission