Title IX Report Form
Note: The University will protect the privacy of individuals involved in a report of Prohibited Conduct to the extent permitted by law and by University policy and procedures. However, it should be recognized that the TIX/SHPC is not a confidential resource. In order to conduct its work and ensure due process for all, the TIX/SHPC staff may need to share information on a need-to-know basis with campus administrators or investigative participants through the course of the University’s response.
Reporting Party Information
(Person making this report)
First Name
Your answer
Last Name
Your answer
Phone Number
Your answer
Email Address
Your answer
Your Affiliation to UCSB?
Note to Law Enforcement
California Penal Code (CPC293) grants victims of alleged sexual violence the right to protect her/his confidentiality by requesting that her/his name not become a matter of public record. If Victim has selected his/her right to confidentiality, please list name as "Confidential".
Complainant Information
(Person who is the subject of the alleged conduct)
Complainant First Name
Your answer
Complainant Last Name
Your answer
Complainant Sex
Relationship to the Respondent
Your answer
Complainant's Affiliation to UCSB?
If Complainant is a UCSB Student, please provide Perm #
Your answer
Respondent Information
(Person alleged to have engaged in the prohibited conduct)
Respondent First Name
Your answer
Respondent Last Name
Your answer
Respondent Sex
Relationship to the Complainant
Your answer
Respondent's Affiliation to UCSB?
If Respondent is a UCSB Student, please provide Perm #
Your answer
Details of Incident
Date of First Incident
MM
/
DD
/
YYYY
Date of Last Incident
MM
/
DD
/
YYYY
Did this occur on campus property?
Location of Incident
Your answer
Was CARE notified of this matter?
Did you file a Clery Report?
Description of Incident
Your answer
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