Anonymous Reporting Form

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This form is meant to be a means for you to anonymously share experiences of discrimination, harassment, or violence. You may share your name, places, or names of other individuals involved, but you have the choice to keep any details private that you wish. This form does not have the ability to track back to you or retrieve any private information.

Because this form is anonymous it may limit Middlebury's ability to follow-up on information or provide supportive measures.

All information will be automatically sent to the Civil Rights & Title IX Coordinator. If you share information to be contacted, you will receive a response as soon as possible.

If you would like more information on who can help on campus and in the community, please visit: https://www.middlebury.edu/office/title-IX/resources-and-support

If an emergency, call 911 or contact Middlebury College Public Safety at (802) 443-5133

You may reach the Civil Rights & Title IX Coordinator : (802) 443-2147 | email: knowyourrights@middlebury.edu | 213 Service Building

Nature of Incident

Discrimination

Sexual Harassment

Stalking

Sexual Assault

Rape

Dating Violence

Domestic Violence

Pregnancy Discrimination

Workplace Violence

Sexual Exploitation

Exclusion based on gender, gender identity, or gender expression

Other:

Did this occur on campus?

Yes

Unknown

Clear selection

Location where the incident(s) occurred:

Date(s) when the incident(s) occurred:

Time(s) when the incident(s) occurred:

Please describe in as much detail as you choose what happened:

Person(s) who experienced harms status:

Student

Faculty

Staff/Administration

Visitor

Alumni

Other:

If person harmed is/was a student, please select from list:

First-year student

Sophomore

Junior

Senior

Graduate

Gender of person(s) harmed:

Race of person(s) harmed:

Ethnicity of person(s) harmed:

Sexual Orientation of person(s) harmed:

Do you know of any clubs or organizations to which the individual(s) who was harmed belongs?

If there was more than one person who was harmed, please provide additional details below:

Person(s) who caused harms status:

Student

Faculty

Staff/Administration

Visitor

Alumni

Other:

If person(s) who caused harmed is/was a student, please select from list:

First-year student

Sophomore

Junior

Senior

Graduate

Gender of person(s) who caused harmed:

Race of person(s) who caused harmed:

Ethnicity of person(s) who caused harmed:

Sexual Orientation of person(s) who caused harmed:

Name of person(s) who caused harmed:

Do you know of any clubs or organizations to which the individual(s) who caused harmed belongs?

If there was more than one person who caused harm, please provide additional details below:

Person filling out this report:

Person Harmed

Witness

3rd Party (i.e.: friend, bystander, professor, etc.)

Person who caused harm

Other:

Please describe your relationship, if any, with those harmed/who caused harm:

Person filling out this report, if you are neither the person who was harmed or who caused harm, how did you learn of this?

If this incident was reported to anyone else, please provide their name here:

If you wish to provide your name or be contacted, please share so below:

Would you like to be contacted? If so, please provide contact information:

Please add any additional information or questions below:

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