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Sexual Misconduct and Gender Based Incidents Report Form

FOR URGENT CONCERNS CALL LAW ENFORCEMENT AT
269-782-6689 or DIAL 911

We encourage all members of the SMC community to be active bystanders and report all incidents of Sexual Misconduct and Bias related incidents. Please visit www.swmich.edu/security/sexual-responsibility for more information about our process. If you are a victim of sexual assault, domestic violence, or Gender related incidents, we strongly encourage you to contact Domestic and Sexual Abuse Services (DASAS) at 269-783-8880 (x8880 from any campus phone) for 24-hour anonymous advocacy and support.

SMC respects the sensitivity of the information that may be included in this form. However, please note that as mandated by Title IX as a federal law, the information included in this form is not confidential, but will be kept as private as possible in all efforts to protect individuals and the greater SMC community.

Nature of Report descriptions:

Choose Sexual Assault/Sexual Harassment/Sexual Misconduct (Title IX) for: Concerns or actions that are experienced or observed that involve sexual assault, sexual harassment, relationship violence, stalking or any violation of the student code of conduct that is based on gender.

Choose FYI for: Concerns or observed actions that you are unsure which nature of category to select, choose FYI.

Please allow 72 hours and know that phone/email information must be completed in the fields below in order to be contacted. If the concern is more urgent, contact Police at 269-782-6689 or call 911.<span

Please remember that all information contained within this report may become part of SMC’s administrative record keeping and may be available to the students to which they pertain under FERPA. Be professional, accurate and factual. Recitations of observations and facts are more useful than characterizations or labels.

Brent Brewer
Title IX Coordinator and Chief of Staff
bbrewer01@swmich.edu
269-782-1276

Background Information

Your full name:

Your position/title:

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Student, Faculty, SMC Employee, Other

Your phone number:

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A number where you can be reached

Your email address:

Email address must be of a valid format.

Your physical address:

Nature of this report(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

Please list the individuals involved, including as many of the listed fields as you can provide. You do not need to complete all parts to add a person. When entering a SMC ID number please be sure to add a Capital N at the beginning of the number.

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Incident Details

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