Title IX Report Form

Background Information

As a reminder: all Whitworth University faculty, staff, and administrators, with the exception of those working in a confidential capacity (e.g., Counseling & Health Center staff, and Chapel clergy) who learn of suspected instances of discrimination, harassment or gender-based misconduct, directly or indirectly, have a duty to report the information immediately.

Your full name:

Your position/title, if any:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Date of incident (if known)(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 (excluding yourself), including as many of the listed fields as you can provide.

Name or Organization

Select Role

ID Number

Phone number

Email address

Residence Hall/Address

Narrative Information

Please complete the fields below.

Please provide a narrative of the incident. Be sure to provide as much information as possible about the incident.(Required) This field is required.

Please indicate other departments that have been notified (optional):

Lutheran Community Services Spokane County Sheriff Whitworth Chapel Whitworth Counseling & Health Center Whitworth Security Whitworth Student Life

You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. Maximum 12 megabytes per file. Attachments require time to upload, so please be patient after you click to submit this report. Attachments must be sent as Microsoft Word or Adobe PDF Files. 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

Narrative Information

Supporting Documentation

Submission