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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: *
Time of incident: * :

Information about the Reporter

Name:

Information about the Victim/Survivor

(if different from above)

Name:

Information about the Offender

Name:

Information about the Conduct

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