Employee Reporting of Sexual Misconduct

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Employee Reporting of Sexual Misconduct

Confidential

Please complete this form as thoroughly as possible. This form may be submitted anonymously.

DATE SUBMITTED

Section I: Complainant Information

NAME

WHAT IS YOUR ROLE AT THE COLLEGE?

GENDER

DEPARTMENT

ADDRESS

CITY

ZIP

Telephone Numbers

HOME

OFFICE

CELL

Section II: Incident Information and Alleged Violations

DATE OF INCIDENT

TIME OF INCIDENT (CLICK AM or PM)

LOCATION OF INCIDENT

CAMPUS WHERE INCIDENT OCCURRED

DESCRIPTION OF THE INCIDENT

Please provide a detailed description of the incident/concern using specific, concise, objective language (who, what, where, why, and how).

Attach Additional pages if necessary.

Section III: Involved Parties

Respondent(s)

NAME

WHAT IS THE RESPONDENT'S ROLE AT THE COLLEGE?

GENDER

DEPARTMENT

ADDRESS

CITY

ZIP

Telephone Numbers

HOME

OFFICE

CELL

ALLEGED VIOLATION(S)

SEXUAL HARASSMENT

SEXUAL ASSAULT

DATING VIOLENCE

DOMESTIC VIOLENCE

INTIMATE PARTNER VIOLENCE

STALKING

IS THERE A SECOND RESPONDENT INVOLVED?

Respondent(s)

NAME

WHAT IS THE RESPONDENT'S ROLE AT THE COLLEGE?

GENDER

DEPARTMENT

ADDRESS

CITY

ZIP

Telephone Numbers

HOME

OFFICE

CELL

Respondent(s)

NAME

WHAT IS THE RESPONDENT'S ROLE AT THE COLLEGE?

GENDER

DEPARTMENT

ADDRESS

CITY

ZIP

Telephone Numbers

HOME

OFFICE

CELL

ARE THERE ANY WITNESSES TO THESE ALLEGATIONS?

Witness(es)

NAME

WHAT IS THE WITNESS'S ROLE AT THE COLLEGE?

GENDER

DEPARTMENT

ADDRESS

CITY

ZIP

Telephone Numbers

HOME

OFFICE

CELL

Witness(es)

NAME

WHAT IS THE WITNESS'S ROLE AT THE COLLEGE?

GENDER

DEPARTMENT

ADDRESS

CITY

ZIP

Telephone Numbers

HOME

OFFICE

CELL

Witness(es)

NAME

WHAT IS THE WITNESS'S ROLE AT THE COLLEGE?

GENDER

DEPARTMENT

ADDRESS

CITY

ZIP

Telephone Numbers

HOME

OFFICE

CELL

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