Title IX Incident Reporting Form

Background Information

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Your full name:

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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.

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 (excluding yourself), including as many of the listed fields as you can provide. For non-students, please list an SSN or Drivers License number in the block labeled SID (Student ID #) if available.

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how). This field is required.

Was Public Safety or another law enforcement agency involved and/or respond?(Required)

Yes No I don't know

This field is required.

Would you like to file a formal complaint at this time? A Formal Complaint means a document submitted or signed by the Complainant or signed by the Title IX Coordinator alleging a policy violation by a Respondent. If you mark yes, you are requesting that the University investigate the allegation(s). If you elect to take no action (mark no), the University may still address a complaint with an appropriate process and remedies and you may still choose to file a formal complaint at a later date.(Required)

Yes- I wish to file a formal complaint No- I do not wish to file a formal complaint at this time

This field is required.

Would you like to receive supportive measures, or information regarding supportive measures? Supportive measures are non-disciplinary, non-punitive individualized services offered as appropriate, as reasonably available, and without fee or charge to the parties to restore or preserve access to the University’s education program or activity, including measures designed to protect the safety of all parties or the University’s educational environment, and/or deter harassment, discrimination, and/or retaliation. Supportive measures may include, but are not limited to: Counseling, Altering campus housing assignments, Campus safety escorts, Implementing contact limitations, Class schedule modifications, and more.(Required)

No- I do not need to request supportive measures at this time Yes- I would like to request supportive measures

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.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission