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Sexual Harassment Reporting Form

TO REPORT AN EMERGENCY OR IF YOU ARE REPORTING AN INCIDENT THAT POSES AN IMMINENT RISK OF HARM TO A PERSON(S) OR PROPERTY CALL CAMPUS POLICE AT 928-776-2185 BEFORE COMPLETING THIS FORM.

This form should be used to report concerns pertaining to possible violations of Yavapai College's Sexual Harassment Policy such as dating violence, domestic violence, hostile environment, sexual assault, sexual exploitation, sexual harassment, stalking, retaliation, or other forms of sexual misconduct.

Yavapai College respects the sensitivity of the information that may be included in this form. Filing this incident report only notifies a limited number of College officials: Yavapai College's Title IX Coordinator, Monica Belknap, and Title IX Deputy Coordinator, Diana Dowling. Please note that as mandated by Title IX as a federal law, the information included in this form is not confidential, but will be kept as private as possible in all efforts to protect individuals and the greater Yavapai College community. Law enforcement will not be notified unless the Accused individual is deemed a significant safety threat to the College community.

Completing this report does not substitute filing a report with Campus Police. To file a report with Campus Police, please call 928-776-2185 and ask to speak with an officer or go to Campus Police which is located at Building 28 at the entrance to the Prescott Campus.

If you are unsure or would like to speak to someone about completing this report form, please call the Title IX Coordinator, Monica Belknap, at 928-776-2211 or Title IX Deputy Coordinator, Diana Dowling, at 928-776-2391.

Background Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(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):

This field is required.

Specific location:

Involved Parties

Please list the individuals involved and include as much identifying - contact information that you can provide. Please note: Witness name(s) and Witness contact information can be provided below in your written describtion to Question 1 below rather than include them as a "Involved Party". You do not need to list yourself in this section.

Name

Select Gender

Select Role

STUDENT ID Number (if known)

Phone number (if known)

Residence Hall/Address (if known)

Questions

Supporting Documentation

Please attach any documents, photos, or videos you have of the incident. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report