Sex Discrimination (TITLE IX) INCIDENT REPORT FORM

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Sex Discrimination (TITLE IX) INCIDENT REPORT FORM

This form may be used by any member of the South College community, including applicants, employees, and third parties, who have experienced or otherwise become aware of a sexual harassment incident. Reports can be submitted at any time, including non-business hours, in person, by mail, by telephone, or by email using the contact information listed below for the Deputy Title IX Coordinator. For complete information on the South College Sexual Harassment (Title IX) Policy go to https://www.south.edu/student-resources/title-ix/.

Campus:

Date of Incident:

Time:

Location of Incident:

Information about the Reporter:

Name:

Phone #:

Email Address:

Affiliation with South College:

Do you wish to pursue a complaint?

Do you request to remain anonymous?

Information about the Victim (If different from above)

Name:

Phone #:

Email Address:

Affiliation with South College:

Do you wish to pursue a complaint?

Do you request to remain anonymous?

Information about the Offender(s) (Please attach additional pages, if necessary)

Name:

Phone #:

Email Address:

Affiliation with South College:

File Upload:

Type of alleged sexual harassment Title IX Concern (check all that apply)

Other:

Reported to Police?

If reported to police, select date reported:

Description of violation/incident

(Please summarize below and attach additional pages and documentation with the form, if necessary)

FileUpload1

Witnesses (Relationship means faculty, advisor, co-worker etc.)

Name:

Relationship:

Telephone:

Name:

Relationship:

Telephone:

Name:

Relationship:

Telephone:

By signing below, I certify the aforementioned information is true and correct:

Signature:

Date:

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