Title IX
What is the nature of your report?
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Sexual Misconduct and/or Interpersonal Violence
Gender Discrimination
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Sexual Misconduct & Interpersonal Violence Reporting Form
This form should be used to report concerns pertaining to possible violations of Southeastern Baptist Theological Seminary’s Sexual Misconduct and Interpersonal Violence Policy such as sexual assault, sexual exploitation, sexual harassment, dating violence, domestic violence, hostile environment, stalking, retaliation, or other forms of gender-based discrimination and harassment. Please note that as mandated by Title IX, the information included in this form is not confidential, but will be kept as private as possible in all efforts to protect individuals and the SEBTS community. Completing this report does not substitute filing a report with Campus Security or the Police Department.To file a report with Campus Security or the Police Department, please call one of the numbers below or go to the Campus Security Office which is located in Broyhill Hall.TO REPORT AN EMERGENCY OR IF YOU ARE REPORTING AN INCIDENT THAT POSES AN IMMINENT RISK OF HARM TO A PERSON(S) OR PROPERTY CALL CAMPUS SECURITY AND WAKE FOREST POLICE DEPARTMENT. FOR EMERGENCIES, please call 911 or the Wake Forest Police Department at (919) 556-9111. FOR NON-EMERGENCIES, please contact Campus Security at (919) 291-1903.
Name
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First Name
Last Name
Phone Number
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-
Area Code
Phone Number
Email
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example@example.com
Southeastern Baptist Theological Seminary or the College at Southeastern affiliation (please check_
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Faculty
Staff
Student
Employment Applicant
Other
Urgency of this report
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Date of Incident
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Month
-
Day
Year
Date
Time
Apprx. time of Incident
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Location
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General location is acceptable
Did an injury occur?
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Yes
No
Involved people or organizations and role (complaint, witness, respondent, student of concern)
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Explanation of how incident occurred:
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Please identify the nature of the incident you are reporting (Check all the apply
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Dating Violence
Domestic Violence
Hostile Environment
Sexual Assault
Sexual Exploitation (i.e. non-consensual photos, videos, or other media)
Sexual Harassment
Retaliation
Stalking
Please provide any information you are able surrounding the incident(s), specifically names, date/time, location of incident, etc. are helpful. Please note, Title IX staff will follow-up for more information.
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Please indicate other departments that have been notified (check all that apply)
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Wake Forest Police Department
Dean of Students Office
HR Department
Campus Security
SEBTS Counseling Center
College Life/House system staff
Graduate Life Staff
Off-campus Resources
Other
Supporting Documentation
Browse Files
Photos, video, email, and other supporting documents may be attached below. 100MB maximum file size
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Submit
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Gender Discrimination Reporting Form
Southeastern Baptist Theological Seminary or the College at Southeastern affiliation (please check_
*
Faculty
Staff
Student
Employment Applicant
Other
Name
*
First Name
Last Name
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Nature of Complaint (please check)
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Gender/Sex discrimination
Gender Inequity
Retaliation
Other
Date of incident
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-
Month
-
Day
Year
Date
Person who discriminated against you (please list the person's full name and title and department (if known).
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Description of Complaint
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Describe your complaint and why you believe this person discriminated / retaliated against you. Explain why you have contact with this individual, e.g. supervisor, co-worker, faculty, etc. Give date(s), time(s), place(s) the discrimination / retaliation occurred.
Please indicate other departments that have been notified (check all that apply)
*
Wake Forest Police Department
Dean of Students Office
HR Department
Campus Security
SEBTS Counseling Center
College Life/House system staff
Graduate Life Staff
Off-campus Resources
Other
Complaint Documentation
Browse Files
Cancel
of
Corrective action sought:
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Describe the corrective action you are seeking.
Witnesses (please include name, title/relationship, and a contact telephone number)
Signature
Date
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-
Month
-
Day
Year
Date
Submit
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