MANDATORY REPORTER INFORMATIONName* First Last Title/Role: Faculty Staff Phone:Email: Enter Email Confirm Email A copy of this completed form will be sent to your email.REPORT INFORMATIONReport Date: MM slash DD slash YYYY Received: In Person Email Phone Call Postal Mail Social Media Phone:Email: Enter Email Confirm Email How did you become aware of the incident: What is your affiliation with Burrell College? Student Faculty Staff Alumni Guest INCIDENT INFORMATIONIncident Date(s): Incident Time(s): Incident Location(s): Campus Building Campus Outdoors Off Campus Campus Sponsored Event Specific Location(s): Incident Type(s): Discrimination Harassment Violence Stalking Retaliation Has this information been reported to law enforcement? Yes No Unsure Agency: Date Reported: MM slash DD slash YYYY Case No.: Protected Class(es) Basis for Report: Sex Gender Gender Identity Gender Expression Sexual Orientation Pregnancy/Parenting Status INCIDENT DESCRIPTIONPlease be as detailed as possible with names, date, and timeRESPONSEI have offered assistance with arranging: Medical Care Mental Health Services Reporting to Law Enforcement Victim Advocate Services I have notified the reporter that this information is being submitted to the Title IX Coordinator Δ