Title IX Incident Report

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Your Name

Who was involved in the incident? check all that apply

Student(s)

Faculty/Staff

A person not affiliated with CSU

Unknown

Date *

What time did the incident occur?

List the name(s) and contact information of those involved in the incident.

Where did the incident occur? *

Describe the incident with as many details as possible. *

Police Report Number (If the police were involved, but you do not know the report number, please enter 'Unknown report number.' If the police were not involved, please enter 'N/A' in the blank.)

How should we proceed with communication? *

Contact me

I wish to remain anonymous to those involved, but you may contact me

I am filing for someone else, who may be contacted

I am filing for someone else, who does not want to be contacted

Do not contact me

Contact (If you wish to remain anonymous, enter 'anonymous.' Otherwise, list the email and phone number of the contact reported in the above question.)

I.P. Address