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Sexual Misconduct Report Form

This form may be completed by any member of the DSU community who has experienced or otherwise become aware of an incident that may constitute a violation of the University’s Sexual Misconduct Policy.

To report a potential violation, please complete the form below. This form should be completed and submitted as soon as possible after learning of an incident that may violate the Sexual Misconduct Policy.  Please answer all questions as thoroughly as possible. If you do not know an answer to a question, please write “Unknown.” If a question may not apply, write “N/A.”

If you have any questions or concerns, contact csanders [at] desu.edu (Candy Young), Title IX Coordinator, MLK Student Center, Suite 317 or call 302.857.6300.

Date of Incident: *
Time of incident: * :

Information about the Reporter

Name:
Physical Address

Information about the Complainant

(if different from above)

Name:
DOB: *

Add Additional complainant if applicable.

Name:
DOB: *

Information about the Alleged Offender (Respondent)

Name:

Information about the Witness

Name:
Physical Address

Information about the Incident

(Who, what, where, when, why and how?)
Date reported to Police/Public Safety (if known):
Has the incident been shared with anyone else?
Internal/External/DSU
Please attach any statements, reports or other documents which you feel are relevant to your complaint.
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.
Has the complainant requested confidentiality?

I CERTIFY THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.