Title IX Complaint Form

This form is used to report incidents of harassment and sexual misconduct related to students and employees of
Elmhurst College. Please fill out this form with the information you are willing to share. All questions are optional and
you may choose to remain anonymous. If you do not provide any identifiable information, this report will be used for
statistical purposes. If you provide a reporter email address, you will receive confirmation that the report has been submitted.

Reporter Information

( Note: you may fill this form out anonymously if you prefer. )
  Your First Name:  
    Your Last Name:  
    Your eNumber:  
    Your Phone:    -  - 
    Your E-mail:  

  Please describe your involvement with this incident:

Survivor Information

( Note: person about whom you are filing this complaint, if it is not you. )
  Survivor First Name:  
    Survivor Last Name:  
    Survivor Phone:    -  - 
    Survivor E-mail:  

Respondent Information

( Note: person against whom you are filing this complaint. )
  Respondent First Name:  
    Respondent Last Name:  
    Respondent Phone:    -  - 
    Respondent E-mail:  
  If there are multiple respondents, please list any available information about any additional respondents.

Witness Information

  Please list any available information about any witnesses present during this incident.

Incident Information

  Date of Incident:     /    /  
  Location of Incident:  
  Type of Incident:  

  Please describe in detail the incident that occurred. Be as specific as possible, including locations,
times, names, direct quotations, etc.
  To whom have you reported this information, other than on this form?
  Do you or anyone involved in the incident have any evidence of the behavior described above?
    ( Examples: Screen shots, call logs, photographs, etc. )

  Please provide any additional information.