Sexual Harassment Reporting Form

Sexual Harassment Reporting Form
This form allows employee of Le Moyne College to report concerns related to sexual harassment, sexual assault, dating or domestic violence, stalking, sexual exploitation, or retaliation, consistent with the College’s obligations under Title IX of the Education Amendments of 1972.

You may submit this report as someone who experienced the behavior, witnessed it, or received a disclosure. As a reminder, most members of the campus community are considered ‘Responsible Employees’ and are required to disclose any potential violations of sexual harassment, sexual assault, and/or gender-based misconduct.

Emergency Situations
If you or someone else is in immediate danger, please call Campus Security at (315)445-444 or dial 911. This reporting form is not monitored 24/7 and should not be used in emergencies.

Before You Submit This Report

This report will be received by the Office of Human Resources. The Office of Human Resources will engage with other appropriate parties, as necessary, to facilitate investigation and resolution in accordance with College policy.
- If you are reporting an incident that happened to you, a member of Human Resources will review your report and follow up within 1–2 business days to offer supportive measures and explain your rights and options.
- This form is not confidential but we will protect your privacy and share information only on a need-to-know basis.
Supportive Measures May Include:
- No-contact directives
- Counseling referrals
- Safety planning
- Assistance with filing a formal complaint to Le Moyne and/or law enforcement (if desired)
You are not required to take any further action after submitting this report, and you may choose to engage with Human Resources at your own pace.

If you are unsure or would like to speak to someone about completing this report, please contact the Office of Human Resources at lemoynehr@lemoyne.edu or 315-445-4155.
Reporter Information
Your Full Name*

First NameLast Name
Your Affiliation with Le Moyne*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nature of This Report*
Date of Incident*

MonthDayYear
Date
Time of Incident*
Location of Incident*
Specific Location*
Involved Parties
If you are completing this as someone who may have experienced misconduct, please provide the following information about the individual(s) you believe discriminated against you, harassed you, or engaged in sexual misconduct toward you. Please remember to include yourself as an involved party and select the appropriate role.

For reports of sexual misconduct, this may include incidents of sexual harassment, sexual assault, dating/domestic violence, stalking, sexual exploitation, and retaliation.

If you are completing this as a Responsible Employee or if you know someone who has experienced discrimination, harassment or sexual misconduct, please indicate all involved parties that were shared with you and their respective roles. If you do not have all of the information, you may leave fields blank.
- Complaintant: individual to whom the misconduct was directed at
- Respondent: indidual who may have violated college policy; federal and/or state laws
- Witness: individual who observed the alleged behavior and can provide additional context or information
- Responsible Employee: Staff, faculty, administrator, etc. that is employed and/or contracted by Le Moyne College and are required to report knowledge of incidents
- Other: individual with knowledge of the event(s) and was not present, and/or involved
Name or Organization*
Role*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Add Another Party*

YesNo
Name or Organization
Role
Phone Number
Please enter a valid phone number.
Email
example@example.com
Questions
Please select ALL alleged violations that apply*

Dating ViolenceDomestic ViolenceGender-Based HarassmentRetaliationSexual Assault/AbuseSexual HarassmentSexual ExploitationStalkingQuid Pro Quo Harassment
Please provide a detailed description of the incident/concern using as much detail as possible.*
Please indicate any other departments that may have been notified, if any.*

Counseling/AdvisingLe Moyne College SecurityOther Law Enforcement AgencyNone
Is there any additional information or details Human Resources should know?
Supporting Documentation
Photos, video, email, and other supporting documents may be attached below.

Cancelof
Should be Empty:

Sexual Harassment Reporting Form

Reporter Information

Involved Parties

Questions

Supporting Documentation