Title IX Incident Reporting Form

Instructions:  Please complete the following online form to the best of your ability.  Report only one incident per form.  Please submit this form to the Title IX Coordinator within 24 hours of becoming aware of any incident. Or if you would rather fill out a paper form you may do so using this form and submit it to TitleIX@nashotah.edu.

Nashotah House Theological Seminary requires that all faculty and staff report issues of sexual violence, discrimination and sexual misconduct to the Title IX Coordinator, Deputy Coordinator or to the Delafield Police Department.

If you are reporting an incident on behalf of someone else, whenever possible, please be sure the person disclosing information to you understands that this form is NOT CONFIDENTIAL, and if you are faculty or staff that you are obligated to report this information to Nashotah House officials.  If the individual does not know that you are reporting his incident, please indicate this in the area below.

If you have any questions, please contact:

Dcn. Esther Kramer, PhD
Title IX Coordinator
Lewis Hall 2nd Floor
TitleIX@nashotah.edu
ekramer@nashotah.edu
262.646.6530
262.309.7661 (cell)
Background Information
Incident Information
:
Involved Parties
You are encouraged to include names of all involved parties (complainant, respondent, witnesses, reporting party)
Please provide the Name of the Organization, Email Addresses, Phone Numbers, Physical Address, and Roles of the individuals involved.
(the day you received the report)
(provide as much detail as possible)
(If yes, please list the names, emails, and phone numbers if known.)
(Photos, email, medical reports, video surveillance, text messages?)
(If yes, please list the types of documentation.)