Today's Date: MM slash DD slash YYYY Name: First Last Phone:Email: Enter Email Confirm Email A copy of this completed form will be sent to your email.Preferred Method of Contact: Phone Email College Affiliation: Student Faculty Staff Alumni Guest Incident Date: MM slash DD slash YYYY Incident Time: : Hours Minutes AM PM AM/PM Incident Location: Campus Building Campus Outdoors Off Campus College Sponsored Event Type of Incident: Discrimination Harassment Violence Retaliation Stalking Specific Location: Protected Class(es) Basis for Report:: Sex Gender Gender Identity Gender Expression Sexual Orientation Pregnancy/Parenting Respondent (An individual who has been reported to be the perpetrator of conduct that could constitute sexual harassment or sexual discrimination): College Affiliation: Student Faculty Staff Alumni Guest Witness 1: College Affiliation: Student Faculty Staff Alumni Guest Phone:Email: Enter Email Confirm Email Witness 2: College Affiliation: Student Faculty Staff Alumni Guest Phone:Email: Enter Email Confirm Email Witness 3: College Affiliation: Student Faculty Staff Alumni Guest Phone:Email: Enter Email Confirm Email Incident Narrative (this can be brief; a full statement will be taken by the investigator):Supportive Measures Requested:Resolution Requested: No Action Informal Resolution Formal Resolution (Investigation and Hearing) Signature:Date: MM slash DD slash YYYY Received By: First Last Date: MM slash DD slash YYYY Δ