Discrimination and Sexual Misconduct Report Form

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

* 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.**

Equal Opportunity Services

Step 1: Your Information

Step 2: Involved Parties

Step 3: Additional Questions

If yes,

Step 4: Supporting Documentation/Attachments

Step 5: Final Review