Title IX and Power-Based Violence (PM73) Report Form

Background Information

If the person completing this form is the victim/survivor, you may choose to identify yourself or not. If you are a third party mandatory reporter who is not the victim/survivor, include the victim/survivor's name and your own.

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Type of Complaint(Required):

This field is required.

Date of incident(Required):

This field is required.

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If unknown - please choose today's date and note in the detail section below that date is unknown

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

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If you are unsure of the location you can type unknown in this field

Involved Parties

Please identify the person(s) and respective roles of individuals involved with the incident(s) being reported.

Name or Organization

Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Providing details will help LSU more fully respond to the incident and a possible investigation. Please know that if the incident is investigated, much of what you share will be provided to the parties. You may also supplement this description later if you wish to share additional details.

Describe the incident(s)/event(s) including date, times, locations, and any potential witness(es) to the behavior.(Required) This field is required.

Have you reported this incident to any of the listed university departments or external organizations?

LSU Police LSU Student Advocacy & Accountability Human Resource Management LSU Cares Baton Rouge Police Department East Baton Rouge Sheriff's Office Louisiana Human Rights Commission Equal Employment Opportunity Commission (EEOC) Other (Please list below)

You must make at least one selection.

If you marked "Other" above, please list who you have notified of this incident. This field is required.

If you are a 3rd party reporter (mandatory reporter), does the individual who is experiencing harassment or discrimination know you are filing this report with the Office of Civil Rights and Title IX?(Required) This field is required.

Supporting Documentation

Please add any documentation that supports 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