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Public Safety
Title IX – Discrimination/Harassment Incident Reporting Form
Discrimination/Harassment Incident Reporting Form
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Please use this section to list the names of the parties involved as well as any witnesses, etc. Enter as much information as possible. If you have included your name above, it is not necessary to add it to this section.
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Name or Organization
Role
(e.g. Accused, Affected Individual, Witness)
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Name or Organization
Role
e.g. Accused, Affected Individual, Witness
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Report Details
Nature of this Report (Select all that apply)
Discrimination
Harassment
Relationship Violence
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Sexual Misconduct (including Sexual Harassment and Sexual Violence)
Stalking
Other
Do you feel this happened because of (select all that apply)
Age
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Genetic Information
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Sex (including Gender, Gender Expression, or Orientation Gender Identity)
Sexual Orientation
Veteran Status
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Incident Details
Date of Incident
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Specific Location of Incident
Have you notified anyone else or any other campus or non-campus unit about this incident? If yes, whom did you notify?
Provide as much detail as you are comfortable with concerning the incident. This will be reviewed by the appropriate staff/faculty member at Alamance Community College.
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