Sex Discrimination, Sexual Harassment & Sexual Misconduct Reporting Form to Title IX Coordinator

Background Information

Your full name:

Learn more

You may remain anonymous; however, that limits our ability to take some actions.

Your phone number:

Learn more

Please provide a safe phone number that we can use to communicate with you, if possible.

Your email address:

Email address must be of a valid format.

Learn more

Please provide a safe email address

Type of Concern(Required):

This field is required.

Relationship to Fresno State(Required):

This field is required.

Date of incident(Required):

This field is required.

Learn more

If unknown, please use today's date

Location of incident(Required):

This field is required.

Specific location:

Learn more

Address, building, apartment complex, etc.

Involved Parties/Witnesses

Please list the individuals involved including as many of the listed fields as you are able to provide. Please also identify individuals who may have observed or witnessed the incident(s).

Name of Individual or Organization

Select Role

ID Number

Phone number

Email address

Information about the Incident(s)

Please provide as much information and detail as possible.

Indicate the type(s) of concern (check all that apply). See the CSU Policy Prohibiting Discrimination, Harassment, Sexual Misconduct, Sexual Exploitation, Dating Violence, Domestic Violence, Stalking, and Retaliation (Nondiscrimination Policy) for definitions.(Required)

Sex or Gender Discrimination

Sexual Harassment

Sexual Misconduct (including Sexual Assault)

Dating Violence or Domestic Violence

Stalking

Sexual Exploitation

Consensual Relationship

Retaliation

You must make at least one selection.

Please provide a detailed description of the incident(s) and be sure to include as much information as possible. As best you are able, please provide date(s), time(s), and location(s).(Required) This field is required.

If possible, describe the specific harm you have suffered resulting from the incident(s). This field is required.

Were any actions taken by you or others to try to resolve the issue? What was the outcome? This field is required.

Were the police involved? If so, please provide the name of the agency, and report number or name of officer involved. This field is required.

If possible, please describe the outcome(s) you are seeking. Be as specific as possible. This field is required.

Supporting Documentation

Please provide any documents, electronic communications or physical evidence that supports your complaint, including but not limited to photos, text messages, tweets, photographs, videos, blood tests or rape kits. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Background Information

Involved Parties/Witnesses

Information about the Incident(s)

Supporting Documentation

Submission