Complaint Form for Harassment, Discrimination, Sexual Misconduct, and Retaliation

Complaint Form for Harassment, Discrimination, Sexual Misconduct, and Retaliation
*Indicates required field
Personal Information (Person making the report)
If you wish to submit this information anonymously, it will limit the ability of the Title IX Coordinator to address the incident. While anonymous reports are used for tracking patterns and assessing campus safety, more information and participation on the part of the person making the report allows the College to promptly and thoroughly investigate. **NOTE: If you are not the victim/survivor (complainant) please list that person's name in the "Involved Parties" section below.**
Your Full Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Nature of Report*
Date of the Incident (approximate if uncertain)*

MonthDayYear
Time of the Incident (approximate if uncertain)

:HourMinutesAM/PM Option
Location of the Incident*
Involved Parties
Under most circumstances, the respondent (the person about whom you are makingn this report) will not be contacted until a College official contacts the complainant (victim/survivor) to explain the process of addressing the report, including his/her options. In extreme situations, the College may have to act quickly on a report that points to an immediate threat to others on campus. If you submit the complainants contact information, every reasonable effort will be made to keep him/her informed.
Full Name

First NameLast Name
Gender
Role
If you selected "Other/Unknown" for the Role, please explain
Phone Number

Area CodePhone Number
E-mail
Hall/Address (if available)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Gender
Role
If you selected "Other/Unknown" for the Role, please explain
Phone Number

Area CodePhone Number
E-mail
Hall/Address (if available)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Incident-Related Questions
Your Role at Illinois College*
On what basis do you believe that the complainant has been discriminated against? If this is a report of sexual misconduct (sexual harassment, sexual assault, domestic or dating violence, or stalking) please check sexual misconduct. (Check all that apply)*

Sexual MisconductGender/SexSexual OrientationGenetic DispositionRaceEthnicityNational OriginColorReligionAgeAncestryDisabilityVeteran StatusOther
If you selected "Other" above, please explain.
Describe each sexual misconduct, discriminatory and/or harassing action separately using the space below. Please be sure to mention the name(s) and/or description of the individual(s) about whom you are making this report.*
Please provide the name and contact information (e-mail or phone, if available) of each witness, if any, including those who may have told you about the incident(s).
Do you believe you have experienced retaliation as a result of speaking to anyone about this incident or making a prior report?*

YesNo
If you selected "Yes" above, please explain what happened to cause you or the complainant to feel retaliated against or threatened with retaliation.
What do you want the outcome to be as a result of submitting this information?*
Have you filed a report with the College Office of Public Safety or local police?*

YesNo
If you selected "Yes", please specificy which.
If you have any documents relating to the reported incident, please upload those now.

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