Report it! | Report It! | Western New Mexico University

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Date of Complaint

I am reporting an incident that affected:

me

someone

Directions

If you believe that you have experienced or witnessed a sexual harassment/assault, you are encouraged to fill out this complaint form. However, depending on the information you provide, the university may investigate without your formal or written consent. The university will take action based on the information provided by you. The information submitted with this form is confidential and abides with HIPAA and FERPA requirements. If you need help during this process, please see the available options here.

Reporter Information:

Name (Reporter) *

W#

Email *

Phone Number *

Individuals Involved

Compliant/s Information

This is the person(s) who you believed was harmed

Name (Complainant ) *

The individual(s) targeted with the alleged act(s) is/are: *

Employee

Student

Authorized/Volunteer

Guest/Visitor

Add Compliant Remove

Respondent/s Information

This is the person(s) who you believed was responsible for the harm

Name (Respondent) *

The individual(s) committed the alleged act(s) is/are: *

Employee

Student

Authorized/Volunteer

Guest/Visitor

Add Respondent Remove

Witnesses

Please list all individuals that witnessed the incident or have knowledge of what you are reporting.

Name (Witness) *

The witness(es)of the alleged act(s) is/are: *

Employee

Student

Authorized/Volunteer

Guest/Visitor

Add Witness Remove

Information regarding the incident/issue.

Locaiton of the Incident:

If this incident occurred in class, provide CRN if possible

Date of the Incident

Time of the Incident

Please describe the alleged incident(s). *

What would you consider an appropriate resolution to your report? *

Additional Documentation - Upload File

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Disclosure

To investigate your complaint, it may be necessary to interview you, the respondent(s), and any witness with knowledge of the allegations or defenses. The statement and the information that you are providing may be attributed to you and could be included in any investigative reports that are prepared. Further, it may be necessary to include you as a witness in any hearing that may occur due to this report.

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