Incident Reporting Form
This form may be used by students, employees, faculty, vendors, visitors or other concerned parties to share information related to an alleged incident(s) of student misconduct, discrimination based on a protected class, including harassment, sexual misconduct and retaliation for making a report or participating in an investigation of the same.

Sexual misconduct includes, but is not limited to, sexual harassment, sexual violence, sexual exploitation, intimate partner/dating violence and stalking. If this is an emergency, please contact the Northwest State Police Department at (419) 267-1452 or, if you are off campus, call 911. Contacting the police does not require you to pursue legal action.

This is a secure reporting format accessible only to the appropriate college officials. You are not required to complete the entire form in order for the complaint to be submitted; however, you must complete fields denoted with an asterisk. The College will use the information provided to address the matter, which means following up with you and/or the affected person and further evaluating to decide upon next steps. Anonymous reports may be more difficult to fully address because college officials will not be able to seek additional information from you.
Background Information
If you wish to identify yourself, please fill in the information listed below. Unless you are an employee reporting on behalf of a student of another employee, you may choose to remain anonymous: however, the college's investigation and response to anonymous complaints likely will be limited. Record the names and contact information, if known, of all other parties in the Involved Parties" section.
Your Full Name:
Your answer
Your Role/Title:
Your answer
Your Phone Number:
Your answer
Your Email Address:
Your answer
Who is the complaint against?
Date of incident (required): *
MM
/
DD
/
YYYY
Time of incident:
Time
:
Location of incident (required): *
Specific location:
Your answer
Involved Parties
Please state the name and contact information (if known) of the person or persons about whom you are reporting and any witnesses and/or other complainants. The complainant is the harmed party and the respondent is the accused party.
List the name of the Complainant(s) (the harmed party) and any contact information:
Your answer
List the name of the Respondent(s) (person accused) and any contact information:
Your answer
List the name(s) of any Witnesses and any contact information:
Your answer
Describe the incident(s) of concern in detail. Include the names of any potential witnesses to the behavior and/or people who may know about the incident. (Required) *
Your answer
If you are completing this form as the person who experienced the misconduct and/or discrimination, what remedy (outcome) are you seeking?
Your answer
As the person reporting this information, do you believe you have experienced retaliation as a result of speaking to anyone about this incident or making a prior report?
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