Title IX Report form

Please note that this report form is on the record. If you wish to stay anonymous, you have the option to fill out the Title IX Anonymous Report form.

Title IX Report Form




Instructions: Fill in all fields that apply. Report only one incident per form. This form will be submitted directly to the Title IX Coordinator.

Your name:

Please identify your relationship with the College:StudentFacultyStaff/AdministratorOther

If Other:

Phone:

Email:

The incident was reported to you by:VictimWitnessThird PartyAnonymous

Date of report:

Date of incident:

Time of incident:

Where did it occur?:

If you wish to avoid specifics, check one of the following: On CampusCollege-Affiliated HousingPublic PropertyOff-CampusOther

Please describe the incident in as much detail as possible:

Do you have reason to believe this incident represents a present threat of harm or danger to the victim or other member(s) of the community?: YesNo

If yes, why?:

Was a weapon involved?: YesNo

Number of alleged assailants/perpetrators:

Alleged Assailant Gender:

Alleged Assailant Race:

Alleged Assailant Age:

Alleged Assailant Height:

Alleged Assailant Weight:

Role of alleged accused/assailant(s) on campus: StudentFacultyStaffNo campus roleUnknown

Name of alleged accused/assailant(s):

Was there any evidence that this incident was motivated by the victim's (check all that apply): RaceEthnicityAgeGenderSexual OrientationReligionOther

Other departments or individuals to whom the victim/reporter has reported this incident:

Name of victim:

Name of Witness 1:

Witness 1 Phone:

Witness 1 Email:

Name of Witness 2:

Witness 2 Phone:

Witness 2 Email:

Name of Witness 3:

Witness 3 Phone:

Witness 3 Email:

Name of Witness 4:

Witness 4 Phone:

Witness 4 Email:

Please describe the resolution you are seeking:

Certification: Check here to certify that all the above information provided on this form is true and accurate to the best of my knowledge or belief.