Title IX Incident Report Form

INCIDENT REPORT FORM FOR VIOLATIONS OF POLICY ON NONDISCRIMINATION, HARASSMENT (INCLUDING SEXUAL HARASSMENT), DISABILITY ACCOMMODATION OR RETALIATION

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 Policy on Equal Opportunity, Harassment and Nondiscrimination. The person making the report, as well as the victim/survivor, may identify themselves or remain anonymous.

To report a potential violation, please complete the form below.

If you have any questions or concerns, contact Candy Young, Interim Title IX Coordinator, MLK Student Center, Suite 317 or call 302.857.6300.

Date of Incident: *

Month

Day

Year

Time of incident: *

Hour

Minute

AM/PM

Location of incident: *

Information about the Reporter

Name:

First:

Last:

Sex:

Race (if relevant to report):

Sexual Orientation (if relevant):

Phone:

Email Address:

Identity of Reporter: *

Information about the Victim/Survivor

(if different from above)

Name:

First:

Last:

Sex:

Race (if relevant to report):

Sexual Orientation (if relevant):

Affiliation to DSU:

Affiliation to DSU: Other...

Residence:

Information about the Offender

Name:

First:

Last:

Sex:

Race (if relevant to report):

Sexual Orientation (if relevant):

Relationship to Victim/Survivor

Number of Offenders:

Affiliation to DSU:

Affiliation to DSU: Other...

Information about the Conduct

Nature:

Physical Injury:

Threat of Physical Injury

Use of Weapon:

Sexual Contact without penetration:

Sexual contact with penetration:

Please provide a brief narrative of the incident:

Reported to Police/Public Safety?

Date reported to Police/Public Safety (if known):

Month

Day

Year

Was the victim/survivor given campus and community resources for services and support?