Discrimination and Harassment Report Form; Including Sexual Misconduct and Sexual Harassment

Background Information

If you wish to identify yourself, please fill in the information listed below.

This section is to identify the person completing the form. You may choose to complete this form anonymously. If you choose to submit a report anonymously, please note that Eckerd will strive to fully respond, but anonymous reporting significantly limits our ability to do so.

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Your Full Name:

Your position/title:

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(Faculty, Staff, Visitor, Outside Community member, etc.)

Contact Information:

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Phone, email, etc.

Your email address:

Email address must be of a valid format.

Your physical address:

Who is the alleged?(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Location Details:

Involved Parties

This section is used to identify the parties involved in the incident. For example: name of the reporting party, name of the responding party, and name of any potential witnesses or third parties involved. As in the section above, please know that not providing the names of the involved parties may limit the College's ability to fully respond to this report.

Name or Organization

Gender

Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Please provide as much information as you can with regard to what/when/where the situation or incident occurred and who was involved. Please include names of any possible witnesses, including anyone with whom you have shared this information and/or any interventions that have been attempted. If there are questions you cannot answer or information you are uncomfortable sharing in this format, simply state that in the appropriate field.

Please describe what you know about the situation. Be as detailed as possible.(Required) This field is required.

Please indicate how you would like to be contacted for follow up. (email, cellphone.) The College will make every effort to maintain your anonymity in accordance with your wishes. There may be limited circumstances when the College would need to contact you despite a request not to; generally, however, such a request will be respected.(Required)

Please contact me - I would like to speak with someone (DON'T FORGET TO PROVIDE YOUR CONTACT INFORMATION ABOVE) You can contact me via email - I want to remain anonymous (create/use a generic email address for communication with the College and remain anonymous) Please do not contact me - I wanted to make a report but do not wish to speak with anyone further about this You can contact me if necessary but I otherwise don't need someone to follow up with me (DON'T FORGET TO PROVIDE YOUR CONTACT INFORMATION ABOVE)

You must make at least one selection.

Supporting Documentation

Please add any additional documents, pictures, screen shots, etc. that support your complaint. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission