Sexual Harassment & Discrimination Formal Complaint Form

Sexual Harassment & Discrimination Formal Complaint Form

This form may be completed by any member of the Prescott College community who has experienced or otherwise become aware of an incident that may constitute a violation of the Title IX Sexual Harassment and Discrimination Policy. Please complete the form to the best of your ability.
- Today's Date
  
  MonthDayYear
- Name*
  
  First NameLast Name
- Recipient ID
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email*
  example@example.com
- Which one(s) do you prefer to be contacted by?
  
  EmailPhoneTextOther
- College Affiliation:*
  
  Undergraduate StudentGraduate StudentFacultyStaffAlumniGuest
- Date and Time of Incident
  
  MonthDayYear
  Date
  Hour MinutesAM/PM Option
- Incident Location*
  
  Campus BuildingOrganization HouseCampus OutsideOff CampusCollege Sponsored EventOther
- If "College Sponsored Event" please specify the location here.
- Type of Incident*
  
  DiscrimenationViolenceHarassmentRetaliation
- Protected Class(es) Basis for Report:
  
  SexGender IdentityGender ExpressionGenderSexual OrientationPregnancy/ParentingRaceColorReligionVeteran StatusDisabilityAgeGenetic InformationMarital StatusNational Origin
- Respondent
  
  First NameLast Name
- Recipient ID
- College Affiliation:
  
  StudentFacultyStaffAlumniGuestOther
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Social Media Accounts
  
  FacebookTwitterInstagramSnapchatTikTokYouTubeOther
- Witnesses
  
  List up to 3 witnesses below
- Witness 1 Name
  
  First NameLast Name
- Witness 1 Recipient ID
- Witness 1 College Affiliation:
  
  Undergraduate StudentFacultyStaffGraduate StudentAlumniGuest
- Witness 1 Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Witness 1 Email
  example@example.com
- Witness 2 Name
  
  First NameLast Name
- Witness 2 Recipient ID
- Witness 2 College Affiliation:
  
  Undergraduate StudentFacultyStaffGraduate StudentAlumniGuest
- Witness 2 Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Witness 2 Email
  example@example.com
- Witness 3 Name
  
  First NameLast Name
- Witness 3 Recipient ID
- Witness 3 College Affiliation:
  
  Undergraduate StudentFacultyStaffGraduate StudentAlumniGuest
- Witness 3 Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Witness 3 Email
  example@example.com
- Please explain what happened in detail.*
- Supportive Measures Requested
  
  No Contact OrderFaculty NotificationOn-Campus CounselingOff-Campus CounselingWork Schedule AdjustmentAcademic AdjustmentResidence Hall RelocationFacility Access PlanCampus Police EscortOn-Campus Medical CareOff-Campus Medical CareVictim Advocate OutreachAssistance Reporting to Law EnforcementAcademic Withdrawal/LOAAcademic Withdrawal (full)Legal Support InformationVisa/Immigration InformationOther
- Do you require an interpreter?
  
  YesNo
- Language
- Do you require accommodations for a qualified disability?
  
  YesNo
- Signature*
- Please verify that you are human*
- Should be Empty:

Sexual Harassment & Discrimination Formal Complaint Form

Witnesses