Title IX Incident Reporting Online Form

Title IX Incident Report 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:

Fr. Jason Terhune
Title IX Coordinator
262-646-6518
TitleIX@nashotah.edu
jterhune@nashotah.edu

Robin Little
Title IX Deputy Coordinator
+1 (202) 306-5352
TitleIX@nashotah.edu
rlittle@nashotah.edu

Incident Report Form

Title IX Incident Report Form

Step 1 of 4

Your Full Name(Required)

Your Position Title(Required)

Your Phone Number

Your E-mail Address(Required)

Your Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of the Incident(Required)

Time of the Incident(Required)

On-Campus - Incident Location

Off-Campus - Incident Location

Parties Involved(Required)

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.

How did you become aware of this incident / situation?(Required)

When did you become aware of the incident?

(The day you received the report)

Describe the incident(Required)

(Provide as much detail as possible)

Are there any other individuals to whom the complaint / victim has reported the incident?

(If yes, please list the names, emails, and phone numbers if known.)

Does the complainant / victim know you are submitting this report?(Required)

Yes

Is there supporting documentation?(Required)

Yes

(Photos, email, medical reports, video surveillance, text messages?)

What type of documentation?

(If yes, please list the types of documentation.)

Who has possession of the documentation?

Name

This field is for validation purposes and should be left unchanged.