Title IX Report Form

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Human Resources
7000 Mercy Road
Omaha, Neb. 68106
Phone: 402-399-2430
Email: titleIX@csm.edu

Title ix Report FORM
Sexual Violence, Sexual Harassment, and Violence against Women

Why use this form?

This form is available for responsible employee reporters of incidents of harassment, including, but not limited to sexual violence and discrimination that you believe may be a violation of College of Saint Mary’s College of Saint Mary Title IX Policy (Sexual Violence, Sexual Harassment, and Violence against Women). Reports can also be made directly to the Title IX Coordinator by phone at (402-399-2430) or by email at titleIX@csm.edu.

Who should use this form?

This form should be used to satisfy the mandatory reporting obligation of all College of Saint Mary employees.

What happens after I fill out this form?

The information is sent to the Title IX Coordinator, who will determine what, if any, action by College of Saint Mary is necessary. You will receive a follow-up message from the Title IX Coordinator.

Is the information in this form confidential?

College of Saint Mary will make every effort to protect the privacy of all involved, but the information you provide in completing this form is not confidential and may be shared as necessary for College of Saint Mary to take the appropriate action.

What if someone retaliates against me for reporting?

College of Saint Mary expressly prohibits any form of retaliatory action against any individual for filing a complaint under this policy or for assisting in an investigation. This prohibition includes intimidation or threats of retaliation.

Do not use this form to report events presenting an immediate threat. If you require emergency assistance, call 911. You may also call Campus Safety and Security at 402-670-8848.

Title IX Report Form

Please note that this report form is on the record. If you are student, you have the option to fill out the Title IX Anonymous Report Form.

Instructions: Fill in all fields that apply. If any information is unknown, please leave the question blank. Report only one incident per form. This form will be submitted directly to the Title IX Coordinator.

Today's Date:

Email:

Name:

Cell Phone:

Please identify your relationship with College of Saint Mary:

Date of Incident:

Time of Incident:

The incident was reported to you by:

Survivor’s Affiliation with College of Saint Mary:

Name of Survivor (if known):

Gender of Survivor:

Relationship of survivor and alleged assailant/perpetrator:

Where did the incident occur?

Description of the incident:

Be as specific about what happened as possible, including information about the people involved. If you are not comfortable providing the name of the survivor/victim you do not have to use real names or provide any other identifying information in your description. Otherwise, feel free to use real names. Please include all pertinent facts, behaviors, comments, gestures, markings, clothing, or other distinguishing characteristics.

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?

Was a weapon involved?

Number of assailants/perpetrators:

Name of assailants/perpetrators (if known):

Assailant(s)/perpetrator(s) affiliation to College of Saint Mary:

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

Race

Ethnicity

Age

Gender

Sexual Orientation

Religion

Other

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.

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