REPORT SEXUAL HARASSMENT/VIOLENCE

IMMEDIATE THREATS

Call Public Safety

or

DIAL 911

Sex Discrimination and Sex-Based Harassment Report Form
This report documents alleged incidents of sex discrimination and sex-based harassment
(including quid pro quo sexual harassment, hostile environment harassment, sexual assault, domestic violence, dating violence, stalking, and sexual exploitation).
Filing this report does not constitute filing a formal complaint.

EMERGENCIES

If there is an immediate risk to health or safety, please call Campus Safety at 618-222-5555 (ext.5555) or 9-1-1.

Call Public Safety

or

DIAL 911

Important Filing Information

*This report may be submitted anonymously. Please note that choosing to make an anonymous report can significantly limit the ability of the College to respond.

**This information is not mandatory but is valuable in allowing the college to look into the concern.
**Reporter’s Full Name
First Last
Reporter’s position/title: (student, Instructor, etc..)
Role at the College
Contact information
** Phone Number
INCIDENT INFORMATION
Date of Incident*
Month
Day
Year
Time of Incident
Campus*
Building
Location*
Other*
Incident Information
Any additional incident information that you feel is important for the reviewing team to know.*
Involved Parties:
Please list the parties involved and provide as much information as you have available to you.

“Complainant”: means a person who is allege to have been subject to conduct constitute sex discrimination.

“Respondent”: means a person who is alleged to have violated the College’s prohibition on sex discrimination.
Please list other involved parties*
Name Role Student ID Number Phone Number
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