Sexual Harassment, Discrimination and Misconduct Reporting Form

Reporting Party Information

A report may be completed confidentially by omitting the reporter's name and contact information from the form. However, the reporting party should be aware that this may restrict the ability to complete a thorough investigation.

Chemeketa strictly prohibits any attempt to seek retribution against an individual or group of individuals involved in filing a report or complaint, participating in the disciplinary process, or opposing an action believed to constitute a violation of College policy.

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Your full name:

Your role:

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Student, staff, faculty, other?

Your phone number:

Your email address:

Email address must be of a valid format.

The incident is between(Required):

This field is required.

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This information will help us appropriately route your concern.

Location of incident(Required):

This field is required.

Involved Parties

Name or Organization

Select Gender

Select Role

K Number

DOB (YYYY-MM-DD)

Phone number

Email address

Physical Address

Questions

Tell me what you are able to remember about the incident:(Required) This field is required.

Have you contacted Public Safety or Law Enforcement?(Required)

Yes No I don't know

This field is required.

If you have an associated report number, please include it here: This field is required.

Has this incident been reported to anyone else?(Required)

Yes No I don't know

This field is required.

If you responded "Yes" to the above, who was it reported to? 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.

Email me a copy of this report

Reporting Party Information

Involved Parties

Questions

Supporting Documentation

Submission