Discrimination & Harassment Reporting Form

Your Information

Please complete the following information about yourself, as the person submitting the report. If you prefer to remain anonymous, please leave this section blank.

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Your full name:

Your role on campus:

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Student, Staff, Faculty, RA, etc.

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

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Urgency of this report(Required):

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Date of incident(Required):

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If the date is unknown, please select today's date and explain further in the incident description.

Time of incident:

Location of incident(Required):

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Specific location, if known:

Involved Parties

Please list the name of all parties who are being reported to have violated college policy (as Responding Party role), the name of the party or parties who are being reported as victims (as Complainant role), and any potential witnesses to the event(s). Include any identifiable information about each person that is known to you.

Name (or Organization)

Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Incident Description

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

If you are not the complainant/victim, is that person(s) aware that you have submitted this report?(Required)

Yes No

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If you want to remain anonymous as a reporting party, please explain the reason for this request. 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

Your Information

Involved Parties

Incident Description

Supporting Documentation

Submission