Title IX Incident Report

Background Information

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Your full name:

Your position/title/role:

Your phone number:

Your email address:

Email address must be of a valid format.

Your local address:

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Involved Parties

Please list the individuals involved (excluding staff members assisting with the incident), including as many of the listed fields as you can provide.

Name

Select Gender (if known)

Select Role

ID Number (if known)

Cell phone number (if known)

Email address (if known)

Hall/Address

Please describe the incident in as much detail as possible.(Required) This field is required.

Is the reporting individual physically safe?(Required)

Yes No - please call the Title IX Coordinator immediately at (585) 270-1696.

This field is required.

Does the reporting individual need medical attention?(Required)

Yes - please call Geneseo University Police immediately at (585) 245-5222 or 911 No Offered but the individual declined/does not want medical care

This field is required.

Does the reporting individual need safe housing?(Required)

Yes - please call the Title IX Coordinator immediately at (585) 270-1696 No

This field is required.

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.

Background Information

Involved Parties

Supporting Documentation

Submission