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Gender-Based Misconduct & Title IX Referral Form

The following form may be used to report incidents of gender-based misconduct, concerns related to Title IX, including sex-based offenses, involving students, faculty and staff to the Title IX Coordinator and Deputy Coordinators.

Reporting Persons Contact Information

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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:

Urgency of this report(Required):

This field is required.

Date of incident or report(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please enter as much information as possible for all individual(s) involved.

Involved party 1

Name or Organization

Select Gender

Select Role

University ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Incident Information

Please answer the following questions as completely as possible.

As the reporter of this concern, what is your affiliation with The University of Akron?(Required)

Faculty Staff Student Police Other

This field is required.

As the reporter of this concern, what is your relationship with the involved individual(s)?(Required) This field is required.

Please provide a description of the incident being referred:(Required) This field is required.

Was a police report filed?(Required)

Yes No Unknown

This field is required.

If a police report was filed, please provide the name of the police department the report was filed with (if known): This field is required.

If a police report was filed, please provide the report number (if known): This field is required.

Has the victim sought medical attention?(Required)

Yes No Unknown

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.

Submission

Email me a copy of this report