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Sexual Harassment and/or Discrimination Report Form

This form should be used by any person to report an incident involving any allegation of sexual misconduct (such as sexual harassment, sexual assault, gender-based harassment, relationship violence, domestic violence and/or stalking), OR incidents of discrimination or harassment based on on any Protected Characteristic such as race, color, creed, religion, sex, national origin, disability, gender identity or expression, ancestry, age, sexual orientation, pregnancy, genetic information, marital status or parental status, veteran or military status, or arrest or conviction record.

Information regarding support resources as well as Western's policies and procedures regarding sexual harassment, harassment and discrimination can be found in the Student Handbook here.

Western Technical College recognizes and respects the sensitivity of the information that may be included in this form. The completed form will be received by the Title IX Coordinator, Ge Vang. Please note that information provided in this form will be kept as private as possible, but is not confidential. The college will investigate and respond to all reports based on the information provided. This report provides notice to the College of alleged policy violations to initiate a response process, but does not obligate the complainant to file a Formal Complaint.

If you are uncertain about what information to include or would like to speak with someone about completing the form, please call the Title IX Coordinator, Ge Vang, at 608-785-9444.

If there is immediate risk or threat to safety, security or health
CALL 9-1-1 IMMEDIATELY
Then call Security at 608-785-9191

Reporting Party's Information

Your full name:

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Leave blank if anonymous

Your phone number:

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Leave blank if anonymous

Your email address:

Email address must be of a valid format.

Type of 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:

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(Ex. Room 101 or east hallway)

Involved Parties

Please list any individuals involved in the incident, providing as much of the information listed as possible:

Name or Organization

Select Gender

Select Role

ID # (Ex 001234567)

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.

Email me a copy of this report