Discrimination and Sexual Misconduct Report Form

IF THIS IS AN EMERGENCY, PLEASE CALL 911 or UH Police AT 713-743-3333. THIS FORM MUST NOT TO BE USED TO REPORT INCIDENTS THAT REQUIRE AN IMMEDIATE EMERGENCY RESPONSE.

You can find information regarding the Sexual Misconduct policy at http://www.uhsystem.edu/compliance-ethics/_docs/sam/01/1d8.pdf

When should you complete this form?

Use this form to report attempted or completed incidents of sexual assault, sexual harassment, stalking, dating violence, domestic violence, or sexual exploitation.

What if you are unsure if this situation falls into one of those categories?

Complete this form to the best of your ability and the Title IX coordinator or designee will determine how the information will be handled.

Can you make an anonymous report?

Yes you may provide information anonymously through this form by leaving your contact information blank.
Or you can report anonymously through UH's Fraud & Non Compliance Hotline.
Please understand, that anonymous reports limit the university's ability to respond and sharing your identity may be helpful to connect you with resources, like medical and counseling services, and provide information about your options for further action.

What if I am a Responsible Employee reporting an incident I have learned about that involves another person?

If you are reporting as part of your requirement as a responsible employee under Title IX, you can identify your role in STEP 3 of using this form.

The information provided in this report can be used by the university to conduct an investigation or take actions to stop the behavior and prevent its recurrence. If you have other questions contact the Title IX coordinator by email or by phone 713-743-8835.

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Step 1: Your Information

Information of person filling out this form.

* First Name

* Last Name

Title

Department

* Status

* Phone Number

* Email

* Nature of this Report

Discrimination
Sexual Misconduct

Incident Date

Unknown

Incident Location

Specific Location

Step 2: Involved Parties

Possible Victim Information (person who may have experienced negative treatment).

Possible Victim name

PSID

Preferred Pronouns

Status

Phone

Email

Alleged Person's Responsible (accused person or person possibly responsible for negative treatment)

Alleged Person's Name

PSID

Preferred Pronouns

Status

Phone

Email

If there is more than one possible victim or alleged person responsible, you can describe their information in your comments later in this form.

Step 3: Additional Questions

* Does either party know you are making this report?

We are required to collect this information.

* When did you become aware of this incident?

* Are you reporting as a Responsible Employee?

Yes No Unsure

If yes,

* What is your PeopleSoft ID?

* What is your Department Name?

* Description of Incident: Provide as much detail as you can regarding the date(s) and place(s) of the incident(s); a detailed description of the specific conduct that is the basis of the concerns; and any witnesses (name and contact information), if applicable.

Other Information: Please provide any other information you believe might be helpful. For example, text messages or other evidence, whether you filed a criminal complaint, and any other extenuating circumstances. You may attach related documents or images in the supporting documentation section below.

* Action Requested:By completing and submitting this form I am requesting the following:

I am initiating a Report of an alleged university policy concern and would like to be contacted with more information regarding my rights and responsibilities outlined in the UHS Anti-Discrimination and/or Sexual Misconduct Policies.

I am submitting this report ANONYMOUSLY and DO NOT want to be contacted further about this matter.

I am still undecided regarding any action to request.

* Have you filed a criminal report with the campus police?

Yes

No

Please note that if you would like to contact University of Houston Police Department, they have a 24/7 phone number 713-743-3333 and more information online at uh.edu/police.

Are you in need of living, class, or work assistance related to this report? If so, please explain.

Step 4: Supporting Documentation/Attachments

Photos, video, email and other supporting documents may by attached below. Each file cannot be larger than 15 MB.

Select files...

Step 5: Final Review

**This page is a preview and form is not complete yet. You must select “Submit” below to send this information to UH Equal Opportunity Services.**