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Responsible Employee - Title IX Reporting Form


THIS FORM IS NOT INTENDED TO BE USED TO REPORT ONGOING OR EMERGENCY INCIDENTS THAT REQUIRE AN IMMEDIATE EMERGENCY RESPONSE.

IF THIS IS AN EMERGENCY, CALL SFA DEPARTMENT OF PUBLIC SAFETY AT (936) 468-2608 or 911.

This form is to be completed by SFA employees, also known as Responsible Employees or Mandatory Reporters, who are made aware, directly or indirectly, of potential misconduct defined by SFA's Title IX Policy 2.13. In accordance with Texas Senate Bill 212 and SFA Policy 2.13, potential misconduct must be reported to the Title IX office within 48 hours of becoming aware of the misconduct.

Potential misconduct includes, but is not limited to, gender-based discrimination, sexual assault, sexual harassment, non-consensual sexual contact, domestic/intimate partner violence, and/or stalking.


For information about the reporting process and other resources please go to www.sfasu.edu/Lumberjacks-Care/ to review the policy please go to the SFA policy page which can be found at the following address www.sfasu.edu/policies/

Follow guidance within this form for each section.

General Information

The General Information section includes information about the employee completing the form. If you are an SFA employee reporting is required by State Law (described in section V (B) Mandatory Reporting Requirement for University Employees of the Title IX policy (2.13)) you are required to complete all information known below.

If you have any questions about completing this form you may contact the Office of Title IX at 936-468-8292 or by email at TitleIX@sfasu.edu

 
Email address must be of a valid format.
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Which of the following is the primary reason for this report?
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Is the person requesting any interim assistance?
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Date of incident, date of most recent incident if this is an ongoing issue, today's date if unknown.
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This can be a specific time or general time frame.
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Please Identify the general location of the incident being reported.
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Please provide detail about the specific location of the incident if known.

Involved Parties

Provide as much information as possible about the individuals involved in the incident. All involved parties, and their names, must be listed in the report if provided to a Responsible Employee in accordance with federal and state law.

Involved party 1

Information Reported

Please provide as much information as possible including but not limited to: the specifics of the alleged misconduct, all known dates, times, and locations, and the impact the misconduct has had on the Complainant's (e.g. person impacted/victim/survivor) employment, learning or living environment, or the their ability to participate in university programs.

Which of the following best describes your relationship to the person that the misconduct impacted?(Required)
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Please use the checklist to indicate the types of documentation you are attaching that pertain to the alleged misconduct.(Required)
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.

Submission