Date: ________ /________ /________
Complainant’s Name:
Complainant’s Affiliation to Monroe College: _____________________________________________________________________________
Complainant’s Phone Number: ___________________________________________________________________________________________
Complainant’s Email Address: ____________________________________________________________________________________________
Offender’s Name: _______________________________________________________________________________________________________
Offender’s Affiliation to Monroe College: _________________________________________________________________________________
Date and Time of Incident: ______________________________________________________________________________________________
Location of Incident: ____________________________________________________________________________________________________
Brief description of Incident (nature of misconduct, context or circumstances, such as spring break trip, on campus event, off
campus party, etc.)
Please provide a detailed description of the incident/concern using specific concise, objective language (who, what, where,
when, why, and how).
Signature: ______________________________________________________________________________________________________________
One of the options you have to report any incident of discrimination, harassment and/or sexual assault is to complete Monroe
College’s online report form. The Incident Report Form is used to provide Monroe College with information for the Title IX Coordi-
nator’s initial assessment which may or may not lead to a formal investigation. You may submit this form anonymously, which may
lead to a preliminary investigation. However, due to the nature of anonymous reporting, it may not be possible to investigate or
resolve reports of discrimination, harassment and/or sexual assault made by anonymously reporting online.
Please email the attached form to Paula Green, Title IX Coordinator at
If you have any questions or concerns regarding the Online Incident Report Form, please contact the Title IX Coordinator,
Paula Green at 914.740.6612 or
NOTE: Submitting an Incident Report Form does NOT initiate a police report.
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