Discrimination and Sexual Misconduct Report Form Step 1: Reporter Information * First Name * Last Name Title Department * Status Please Choose... Student Staff Faculty Visitor to Campus Unaffiliated * Phone Number * Email * Nature of this Report Discrimination Sexual Misconduct Race/Origin Color Sex Age Religion Disability Veteran Status Genetic Information Gender Expression Gender Identity Sexual Orientation Sexual Harassment Non-Consensual Sexual Contact Sexual Assault Sexual Exploitation Sexual Intimidation Dating Violence Domestic Violence Stalking Retaliation Failure to Report Incident Date Unknown Incident Location Please Choose... On Campus Off Campus Unknown Specific Location Next Step 2: Involved Parties Victim Information Victim Name PSID Preferred Pronouns Status Please Choose... Student Staff Faculty Visitor to Campus Unaffiliated Phone Email Alleged Responding Party Information Responding Party/Alleged Name PSID Preferred Pronouns Status Please Choose... Student Staff Faculty Visitor to Campus Unaffiliated Phone Email Previous Next Step 3: Additional Questions * Does either party know you are making this report? Please Choose... Yes, I was directly impacted by this incident. Yes, at least one party is aware that I am making this report. No, neither party is aware that I am making this report. * When did you become aware of this incident? * Are you reporting as a Responsible Employee? Yes No Unsure If yes, * What is your PeopleSoft ID? * What is your Department Name? * Description of Incident: Provide as much detail as you can regarding the date(s) and place(s) of alleged violation(s); a detailed description of the specific conduct that is the basis of alleged violation(s); and any witnesses (name and contact information), if applicable. Other Information: Please provide any other information you believe might be helpful. For example, text messages or other evidence, whether you filed a criminal complaint, and any other extenuating circumstances. You may attach copies of documents pertaining to the alleged violation using the supporting documentation section below. * Action Requested:By completing and submitting this form I am requesting the following: I am initiating a Report of an alleged university policy violation and would like to be contacted with more information regarding my rights and responsibilities outlined in the UHS Anti-Discrimination and/or Sexual Misconduct Policies before an investigation is started. I am submitting this report ANONYMOUSLY and DO NOT want to be contacted further about this matter. I am still undecided regarding any action to request. * Have you filed a criminal report with the campus police? Yes No * Would you like to file a criminal report with the campus police? Yes No Are you in need of living, class, or work assistance related to this report? If so, please explain. Previous Next Step 4: Supporting Documentation/Attachments Photos, video, email and other supporting documents may by attached below. Each file cannot be larger than 15 MB. Select files... Previous Next Step 5: Final Review Previous Submit Report