Title IX and Policy Against Harassment and Discrimination Reporting Form

Title IX and Policy Against Harassment and Discrimination Reporting Form
Members of the Wisconsin Lutheran College community who have experienced or witnessed harassment, discrimination, sexual misconduct, or retaliation may use this online form to communicate with the College.

The content submitted in this form will be sent to the Title IX Coordinator for triage and response. All of the fields in the form are optional. The person using this form may choose to remain anonymous by not inputting their name, contact information, or other personally identifying information. Please note that remaining anonymous will limit the Title IX Coordinator’s ability to offer supportive measures.

When the college is unable to offer supportive measures/formal grievance process to an alleged violation of the Title IX and Policy against Harassment and Discrimination because information is provided anonymously, the College will nonetheless take steps to limit the effects of any actions that violate the policy and will work to prevent any recurrence of violation.
Your full name:
Leave blank if you wish to remain anonymous
Your phone number:
Leave blank if you wish to remain anonymous
Your email address:
Leave blank if you wish to remain anonymous
Your mailing address:
Leave blank if you wish to remain anonymous
Alleged violation of Title IX and Policy Against Harassment and Discrimination - select all that apply:

Sex DiscriminationSexual HarassmentSexual Assault (rape, fondling, incest, statutory rape)Sexual ExploitationDomestic ViolenceDating ViolenceStalkingHazingRetaliationHarassment (general)
Are any of these protected statuses the basis for the alleged policy violation(s)? Select all that apply:

Race/EthnicityNationalitySex/GenderAgeMarital StatusSexual OrientationGenetic PredispositionReligionVeteran StatusDisability
Location of incident:

On campusOff campusBoth on and off campus
Victim(s) name(s):
Leave blank if anonymous
Victim(s) contact information (as available: name, phone, email, address, social media usernames):
Leave blank if anonymous
Witness(es) name(s):
Leave blank if anonymous
Witness(es) contact information (as available: name, phone, email address, social media usernames):
Leave blank if anonymous
Describe the incident(s) or event(s). What happened? Describe your actions and reactions. Who else saw or heard? Include date(s), time(s), and location(s).
What impact has/have the incident(s) or event(s) had on you?
Have you taken any action to stop the behavior?
What remedy do you seek?
Should be Empty: