Sexual Harassment Reporting Form

Background Information

This information can be provided by the Complainant (Victim/Survivor), Faculty, Staff, Students, and 3rd Parties. To help ensure effective assistance from the Office of Title IX and Clery Compliance, please provide as much information as possible.

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Your full name:

Employee or Student:

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If Employee, please give your title

Your cell phone number:

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Or best contact number to reach you

Your email address:

Email address must be of a valid format.

Your physical address:

Alleged Sexual Misconduct(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

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Please provide the location of the incident

Specific location:

Involved Parties

CONTACT INFORMATION FOR THOSE INVOLVED- Please list the individuals involved, beginning with the primary person you are reporting (Reporting Party/Victim), followed by others who also may have been involved (Responding Party/Accused) or who witnessed the incident, complete as many of the listed fields as you can.

Party or Organization's Full Name

Select Gender

Select Role

Banner ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Address

Questions

Please provide as much information as possible.

Complainant's relationship with Respondent? This field is required.

Using specific, concise, and objective language, please provide a brief description of the specific incident that occurred. Avoid using pronouns, i.e., he, she, etc. to identify people. Use the person's real name when known otherwise give the name you know the person by. Indicate specific words, phrases, interaction, and behavior. Give dates and times. If a subject used profanity, made threats, or spoke of self-harm or harm to others, indicate specific words/phrases used. If a student was loud or disruptive, indicate behaviors associated with the disruption, and describe any injury or damage to person(s) or property. Include any actions taken, if any. Please be very detailed in your response (Who, What, When, Where, Why, and/or How). This field is required.

Did you tell anyone about the alleged incident (student/university employee, police officer, &/or medical provider)? If so, please provide the name(s), date, and contact information of whomever you spoke. This field is required.

While not required, was the incident reported to campus or local law enforcement? This field is required.

Supporting Documentation

Explain any documentation supporting the 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