Discrimination, Harassment & Retaliation, Sexual Misconduct Report

Complainant Information

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Your full name:

Your phone number:

Your email address:

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Type of Report(Required):

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Date of incident(Required):

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Location(Required):

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Specific Other location:

Involved Parties

Please provide all known information regarding the people involved in this concern. Include the Respondent and any people who might have information about the concern.

Name

Reporting Party/Responding Party/Information

ID Number

Phone number

Email address

Information and Acknowledgements

Please provide the information requested and respond to the acknowledgements below.

Please provide a description of the events that the Complainant believes constitute Discrimination, Harassment, Retaliation, and/or Sexual Misconduct.(Required) This field is required.

Depending on the information provided, the University may have the obligation to: (A) disclose the names of the Complainant and Respondent, as well as relevant facts about the alleged events, including date, time and location, to the Title IX Coordinator, the University Counsel and other University officials and employees pursuant to the DCP, and (B) investigate these concerns whether or not a Complaint is filed.(Required)

I acknowledge.

You must make at least one selection.

I understand that I have the right to contact law enforcement authorities to discuss whether the events you have described may be grounds to file a criminal complaint.(Required)

I acknowledge.

You must make at least one selection.

Please acknowledge that the Discrimination Complaint Procedures have been made available to you for your review by the hyperlink at the top of the form.(Required)

I acknowledge.

You must make at least one selection.

Please acknowledge that if you request that your identity be kept confidential, the University will evaluate, and grant or deny such request in the context of the University's responsibility to provide a safe and nondiscriminatory environment to all students and employees. Among other things, a request for confidentiality by the Complainant may limit the University's ability to initiate or to investigate the Complaint or to impose sanctions or disciplinary action against the Respondent. Filing a complaint is consent to disclose the complaint and information gathered during the investigation under the Family Educational Rights and Privacy Act (FERPA).(Required)

I acknowledge.

You must make at least one selection.

Please type your name in the box to serve as your electronic signature. This field is required.

I request to remain confidential and that my name and personal information not be disclosed to the individual(s) who I believe have discriminated, harassed, or retaliated against me. If confidentiality is requested, the University will evaluate and may grant or deny.(Required)

Yes No

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I am reporting:(Required) This field is required.

I understand that referrals from this form will be received during normal business hours (M-F, 8AM - 5 PM) and are not monitored after hours, on weekends, or during official University holidays. Please contact UNC Police at 970-351-2245 if there is an immediate risk of harm to self or others prior to submitting this form.(Required)

I acknowledge.

You must make at least one selection.

Supporting Documentation

Please attach any supporting documentation that would provide information for your report. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Complainant Information

Involved Parties

Information and Acknowledgements

Supporting Documentation

Submission