Title IX and DHR Reporting Form

Background Information

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Your full name/pronouns:

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If you are NOT a Sac State employee, you may write Anonymous

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

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Choose an option that best represents the incident being reported.

Date of incident(Required):

This field is required.

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If exact date is unknown, please enter an approximate date.

Time of incident:

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If exact time is unknown, please enter an approximate time.

Location of incident(Required):

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Specific location:

Involved Parties

Please include the following: the name of the person reportedly harmed and their role as the Complainant, the name and role of the Respondent (if known), and the names and roles of any witnesses or bystanders who may have witnessed the behavior. If you do not know the name of the Respondent, please type, Unknown Respondent in the name field.

Definition of Roles:

Complainant: The individual who experienced the alleged behavior.
Respondent: The individual who engaged in the alleged behavior.
Witness: An individual who has a first-hand account of the alleged behavior.
Bystander: An individual who has a first-hand account of the alleged behavior and who tried to intervene to stop the alleged behavior.

Name or Organization

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Details About the Reported Conduct

The Complainant/victim/person who experienced the harm is a:(Required) This field is required.

The Respondent/perpetrator/person who caused the harm is a:(Required) This field is required.

The person filing this report is a: This field is required.

If you're filing a report of Discrimination or Harassment, select which Protected Status(es) you believe motivated the behaviors/actions the Complainant experienced. This field is required.

If 'More than one Protected Status' or 'other' is selected, please explain: This field is required.

Please describe the incident/concern in as much detail as possible. Use specific, concise, objective language (Who, what, where, when, why, and how).(Required) This field is required.

If you are filling this report out about your own experience, please describe the outcome(s) you expect from filing your complaint. Be as specific as possible. This field is required.

Please indicate if other on/off campus departments that have been notified:

Athletics University Housing Services Student Conduct Student Organizations & Leadership University Police Other

You must make at least one selection.

If 'other' is selected, please write what other resource(s) was notified: (e.g., Academic Affairs, Student Affairs, Faculty/Staff, WEAVE, Sacramento PD/Other Outside Law Enforcement Agency, etc.) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Details About the Reported Conduct

Supporting Documentation

Submission