External - Responsible Employee Reporting Form (P. SAFETY)

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Fields

Title IX Incident Reporting Form

Date Incident Was Reported to You*

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Month

Day

Year

Date Incident Occurred

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Month

Day

Year

Your Name*

First Name*

Last Name*

Your Phone #*

I am?*

If multiple incidents were reported or if the date the incident occurred is unknown, please note below:

Reporting Person Contact Information (Person whom reported to you)

Reported by:*

Victim Witness

Other: Other Value

Full Name*

First Name*

Last Name*

Email*

Phone Number*

If a third party reported the crime to you, please enter the relationship of the third party to the victim:

Agency Notified

If, to your knowledge, a law enforcement agency was notified, please enter the name of that agency.

Agency Name:

Does the victim want the incident reported to law enforcement?

Yes No

Incident Information

Please note that sex offenses, domestic violence, dating violence, and stalking are reportable offenses under the Clery Act. The information listed below is helpful in determining which incidents are reportable under both the Clery Act and Title IX.

Name of person who experienced sexual violence (if known):

First Name

Last Name

Location of incident (building name, street address, office number):*

Time of incident (if known):

Hour

Minute

AM/PM

Incident Description (please provide specific, detailed information)*

Name of alleged perpetrator (if known):

First Name

Last Name

Other students involved in the incident:

Location

What best describes the location of the crime? (If the incident occurred in multiple places, check all that apply.)*

On Campus, residence hall On Campus, not in a residence hall Public property immediately adjacent to campus Non-campus in a University owned leased or controlled space (fraternity, sorority, off-campus classroom) Unknown location, other I do not know which category this location would fall under.