Fillable Harassment Complaint Form CAMPUS WIDE INCIDENT REPORT FORM

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Harassment Complaint Form CAMPUS WIDE INCIDENT REPORT FORM

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1
SEXUAL & OTHER PROHIBITED HARASSMENT COMPLAINT FORM
Oral Roberts University has an expectation that all students, administrators, faculty, staff and
contractors of ORU will promptly notify administration regarding incidents that involve
inappropriate conduct or behavior as defined in the “Sexual and Other Prohibited Harassment”
section of the in the Employee Handbook and the Student Handbook. This form is intended to
provide ORU’s students and employees with a method to file a complaint so that it can be
investigated promptly. Please complete this form within 24 hours, or as soon as possible, after
the incident to enable us to assess the danger the incident represents to the community at large.
Annual statistical information will be based on this report, as will the need to make timely
warnings to the community, for the protection of those who may be at risk.
Instructions: Fill in all fields that apply. Report only one incident per form. Take more space
than is given on this form, as necessary, to complete the descriptions. Employees should report
the incident to their supervisor or their supervisor’s superior if the supervisor is the source of the
alleged harassment. Students are to return this form to the Dean of Women or the Dean of Men,
or the Vice President for Student Life, as appropriate, within 24 hours of becoming aware of any
incident. All reports of sexual harassment and violence should be reported to the Director of
Human Resources, who serves at ORU’s Title IX Coordinator.
Your name: ________________________________Your Z Number: ______________________
Phone Number: __________________________ E-mail:_______________________________
You are the: (check one) victim witness third-party anonymous
Date of Report: _______________ Date of incident: ____________ Time of incident:_________
Where did the incident occur?_____________________________________________________
If you wish to avoid specifics, check one of the following: On Campus Residence Hall
Public Property Off-campus Other (Please see descriptions of these four categories
on page 3, for proper classification)
Name of victim ________________________________________________________________
Contact information for victim ____________________________________________________
Please describe the incident in as much detail as possible _______________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you have reason to believe this incident represents a present threat of harm or danger to the
victim or other member(s) of the community? Yes No
If yes, to whom and why: _________________________________________________________
______________________________________________________________________________
Was a weapon involved? Yes No Number of assailants/perpetrators:_______________
If a single assailant/perpetrator, describe:
gender:
race:
age:
height:
weight:
Role of assailant/perpetrator(s) on campus (check one): student faculty staff
no campus role unknown
Name of alleged assailant(s):______________________________________________________
Was there any evidence that this incident was motivated by the victim’s (check all that apply):
race ethnicity age gender sexual orientation religion
Other departments or individuals to whom the victim/reporter has reported this incident
______________________________________________________________________________
Names and contact information for any witnesses______________________________________
______________________________________________________________________________
______________________________________________________________________________
3
Is there any other information that you would like to share that was not asked on this form? If so
please include it here.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The term 'campus' means:
“any building or property owned or controlled by ORU within the same reasonably
contiguous geographic area of ORU and used by ORU in direct support of, or in a manner
related to ORU's educational purposes, including residence halls, and Mabee Center;
property within the same reasonably contiguous geographic area of ORU that is owned by
ORU but controlled by another person, is used by students, and supports institutional
purposes (such as a food or other retail vendor).”
If an incident occurred on campus in a residence hall, please circle both “On Campus” and
“Residence Hall” on this form.
* The term 'off-campus’ means:
“any building or property owned or controlled by a student organization recognized by the
institution; and
any building or property owned or controlled by ORU, such as CityPlex, that is used in
direct support of, or in relation to, the institution's educational purposes, is frequently used
by students, and is not within the same reasonably contiguous geographic area of the
institution.”
* The term 'public property' means...
“...all public property that is within the same reasonably contiguous geographic area of the
institution, such as a sidewalk, a street, other thoroughfare, or parking facility, and is
adjacent to a facility owned or controlled by the institution if the facility is used by the
institution in direct support of, or in a manner related to the institution's educational
purposes.''
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Harassment Complaint Form CAMPUS WIDE INCIDENT REPORT FORM

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Completed 20 February 2020

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