Sex Discrimination and Sexual Misconduct/ Power-Based Violence Report Form

Background Information

If you wish to identify yourself, please fill in the information listed below.

If the person completing this form is the victim, you may choose to identify yourself or not. If you are a third party complainant who is not the victim, include the victim's name.

Your full name:

Your position/title:

Your phone number:

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/Witnesses

Please identify the person(s) involved in the incident and select the role for each person.

Name

Gender

Role of each person identified in incident.

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

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.

titleix@ulm.edu; carradine@ulm.edu; simmons@ulm.edu

ULM Title IX Office

Sherrye Carradine

Latricia Simmons

Email me a copy of this report

Background Information

Involved Parties/Witnesses

Questions

Supporting Documentation

titleix@ulm.edu; carradine@ulm.edu; simmons@ulm.edu

Submission