Date: ________ /________ /________
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).
INCIDENT REPORT FORM
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 firstname.lastname@example.org.
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 email@example.com
NOTE: Submitting an Incident Report Form does NOT initiate a police report.
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