Title IX Incident Reporting Form - Sexual Harassment and/or Sexual Misconduct

Reporting Party Information

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Your full name:

Your position/title:

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Student, Faculty, Staff, Other:

Your phone number:

Your email address:

Email address must be of a valid format.

Type of Incident Reporting(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

In this section, you can list the respondent (the person who allegedly has committed a violation of Title IX). We also request that you list any and all individuals who may have observed or witnessed the incident(s) that are described. Please list as much information as you have about each individual.

Name of Student, Staff, Faculty member, or Organization

Gender Identity

Role

ID Number (if known)

Phone number

Email address

Hall/Address (if known)

Questions

Describe the incident(s) or events(s), date(s), time(s), and location(s) giving rise to this report.(Required) This field is required.

What is/are the person(s) involved relationship/association with Harvey Mudd College? What is/are the persons(s) involved relationship/association with you (the reporting party)?(Required) This field is required.

Describe the specific harm the potential complainant has suffered resulting from the incident(s) or any potential witnessed harm(Required) This field is required.

What did you or others do to try to resolve the complaint? What was the outcome? This field is required.

Do you have any physical evidence (such as photographs, videos, text messages, clothing, etc.) that support the complaint? (Please describe.) This field is required.

You may elect to have a support person present at meeting(s) and/or interview(s) which may be a friend, family member, advocate or support person. 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 complaint. The role of the Advisor is limited to observing and consulting with you. If you plan to be accompanied by an Advisor, please provide the name and telephone number of the individual who will accompany you. This field is required.

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

Yes No

You must make at least one selection.

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