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.

Incident Information
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.
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.
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.
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.
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*

Clear
Please verify that you are human*
Should be Empty:

Sexual Harassment & Discrimination Formal Complaint Form

Witnesses