DOWNTOWN BROOKLYN
151 Lawrence Street
Brooklyn, NY 11201
Tel: 718 - 522-9073
DANIA BEACH
225 E Dania Beach Blvd, Suite 120
Dania Beach, FL 33004
Tel: 786-279-1740
HIALEAH
530 West 49th Street
Hialeah, FL 33012
Tel: 786-279-2643
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel: 212-672-6450
WWW.ASA.EDU
SEXUAL MISCONDUCT REPORT FORM
COMPLAINANT’S INFORMATION (if different from reporter)
Complainant’s Name: Complainant’s Affiliation to ASA College
(Student, Faculty, Staff, Unaffiliated):
Is Complainant Safe? Were Any Emergency Services Used? (If yes, List)
Complainant’s Contact Information (if available)
Telephone: E-mail:
Brief Description of Incident (Nature of misconduct, context or circumstances, such as spring break trip, on campus event, off campus party, etc.):
Other Individuals Present or Involved
(List names and affiliation to ASA College - Student, Faculty, Staff, Unaffiliated):
REPORTER’S INFORMATION (Required, if other than Complainant):
RESPONDENT’S INFORMATION
Respondent’s Name (if known): Respondent’s Affiliation to ASA College
(Student, Faculty, Staff, Unaffiliated):
Reporters Name: Date of Report:
Reporters Affiliation to ASA College Reporters Contact Information:
Telephone
E-mail
INCIDENT INFORMATION
Date and Time of Incident: Location of Incident
Page 1 of 4
(Student, Faculty, Staff, Unaffiliated):
DOWNTOWN BROOKLYN
151 Lawrence Street
Brooklyn, NY 11201
Tel: 718 - 522-9073
DANIA BEACH
225 E Dania Beach Blvd, Suite 120
Dania Beach, FL 33004
Tel: 786-279-1740
HIALEAH
530 West 49th Street
Hialeah, FL 33012
Tel: 786-279-2643
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel: 212-672-6450
What is Sexual Misconduct?
Who is required to report Sexual Misconduct?
Are there College employees who may keep reports of Sexual Misconduct confidential?
Page 2 of 4
Sexual Misconduct includes: Rape, Sexual Assault, Sexual Coercion, Sexual Harassment, Domestic and Dating Violence,
Stalking, and all other forms of Sexual Violence.
Any ASA College employee, whether faculty, or staff, who receives a complaint or otherwise learns about a possible incident
of Sexual Misconduct involving a member of the ASA College community as Complainant or alleged Respondent must
complete this report form. You may also use this form to report an incident of Sexual Misconduct if you are the Complain-
ant/Reporting Individual or if you are not an ASA College employee.
ASA College does not have a health or counseling center or a chapel or ministry. Because of the unavailability of these resourc-
es, confidential havens do not exist on ASA College campuses and as a result ASA does not accommodate requests for Confi-
dentiality. Students and staff who may want to talk to someone about something they have observed or experienced, even if
she/he is not sure that behavior constitutes Sexual Violence are urged to contact the Confidential Hotline at CAMBA,
1-800-310-2449 or Wyckoff Heights Medical Center, 718-906-3846/3857. Students and staff who do not wish to disclose to
ASA College a complaint of Sexual Misconduct may seek assistance with confidential health, rape crisis services, police and
court advocacy services, mental health counseling, victim/survivors benefit services; information and referral services related
to assistance in filing Crime Victims compensation with the NYS Office of Victim Services from these external resources. ASA
College has MOU agreements with these agencies.
What if a complainant requests confidentiality?
Even if a complainant requests confidentiality or is unwilling to proceed with a complaint, ASA College employees are
required to report the complaint to a Title IX Coordinator. If confidentiality is requested, the College will take reasonable steps
to investigate and respond to the complaint, consistent with the complainant’s request. In all cases, the College will weigh its
responsibility to provide a safe and nondiscriminatory environment against the complainant’s request for confidentiality. The
determination of whether and how to proceed will be made by the Title IX Coordinator in consultation with the Complainant.
What interim measures are available to the Complainants?
The Title IX Coordinator may implement interim measures pending the investigation of a report or complaint to prevent contact
between a Complainant, an accused party, and anyone involved in the investigation.
Interim measures are helpful to ensure the safety of all parties to the investigation, prevent retaliation, and avoid an ongoing
hostile environment. Such measures may include but are limited to: (1) Issuing a “no contact order” whereby intentional
contact shall be a violation subject to disciplinary procedures; (2) Interim suspension after it is determined that the accused
presents a continuing threat to the health and safety of the rest of the College community; and (3) Providing increased security;
supervision or monitoring at locations or activities where the alleged misconduct occurred; adjustment to housing or living
arrangements; reasonable adjustment to class or College work schedule; or change in campus location to attend classes. Such
remedies are designed to prevent recurrence, to alleviate pain, embarrassment, and aggravation associated with Sexual Miscon-
duct.
Consent Requirement:
However, before any discussion to proceed with an investigation of a reported Sexual Misconduct allegation, the Title IX Coor-
dinator will request the consent of the Reporting Individual prior to beginning an investigation. If the Title IX Coordinator
request is denied to proceed, there are several instances under which the Title IX Coordinator will proceed with an investigation
without the written consent of the Reporting Individual/Complainant to proceed with an investigation:
The increased risk that the accused will commit additional acts of violence or similar Misconduct;
Whether the accused has a history of violent behavior or is a repeat offender;
Whether the victim is a minor;
Whether the accused used a weapon or force in the reported incident;
The incident is an escalation of previous behavior;
• Whether the incident represents escalation in unlawful conduct on behalf of the accused from previously noted behavior,
such as a situation that previously involved sustained stalking;
Evidence is obtained by other means; such as security footage and whether the report reveals a pattern of perpetration at a
given location or by a particular group.
Did you provide consent to the ASA College Title IX Coordinator to conduct an Investigation: Yes No.
Name: _______________________________________ Signature: __________________________ Date: ______________
click to sign
signature
click to edit
DOWNTOWN BROOKLYN
151 Lawrence Street
Brooklyn, NY 11201
Tel: 718 - 522-9073
DANIA BEACH
225 E Dania Beach Blvd, Suite 120
Dania Beach, FL 33004
Tel: 786-279-1740
HIALEAH
530 West 49th Street
Hialeah, FL 33012
Tel: 786-279-2643
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel: 212-672-6450
Summary of the preliminary investigation:
The Title IX Coordinator will conduct a preliminary investigation to assess whether this Policy or the Student Code of Conduct
may have been violated. If the Title IX Coordinator determines that there was a finding of Sexual Misconduct, the Title IX
Coordinator will notify the Respondent in writing that a complaint has been filed and provide the factual allegations concerning
the alleged violation, and possible sanctions.
The Title IX Coordinator will schedule a meeting with the Respondent, within a reasonable amount of time, and ensure the
Respondent is provided with a written explanation of all available resources and options, and is offered the opportunity to
discuss those resources and options.
Wherever possible, simultaneous notification will be given to both parties (Complainant and Respondent) either by personal
delivery; overnight mail with signature requirement; certified mail with return receipt to the address in ASA College’s records;
and/or by email to the Complainant’s and Respondent’s ASA College’s email accounts. The notice shall contain: (1) the date,
approximate time, and location of the alleged violation; (2) a description of the factual allegations; and (3) a summary of poten-
tial sanctions associated with the alleged violation.
The notice shall inform the Complainant and the Respondent of the right to bring an advisor to meetings and ensure there is a
clear understanding that the role of the advisor is to support and advise, not to speak on the behalf of the Complainant or
Respondent or to take any action that may interfere with the integrity and process of the investigation.
The Investigator will interview the parties about the complaint, as well as any witnesses who have been identified. The Investi-
gator will ask the parties for any documentary, electronic, or other evidence related to the complaint that they want to offer.
Prior sexual history with persons other than the charged party in a disciplinary proceeding is not considered evidence and will
be excluded. Also, the mental health diagnosis and/or treatment of the parties will be excluded from the decision stage of the
disciplinary process that determines responsibility. However, past findings (especially repeated offenders) of Domestic
Violence, Dating Violence, Stalking or Sexual Assault may be admissible when determining sanctions. All individuals who are
interviewed shall be advised to maintain privacy of the investigation process and not to disclose any information related to the
complaint unless necessary during the complaint process. Maintaining privacy is important to preserve the integrity of the
investigation and deter retaliation.
It is generally the Complainant’s decision whether to file a complaint or to continue with any form of resolution. If the Com-
plainant elects to initiate a formal complaint against another person or group of persons, a Sexual Misconduct Report Form is
filed with the Title IX Coordinator, and an investigation is conducted.
Please provide the information requested and deliver the completed form to:
What happens with the information I provide?
Page 3 of 4
Once a complaint or notice of allegation of Sexual Misconduct is received, the Title IX Coordinator will make an initial assess-
ment of the reported information and respond to any immediate health concerns raised by the report, including interim reme-
dies.
The Title IX Coordinator will provide the Complainant with a general understanding of this Policy and the process for respond-
ing to complaints of Sexual Misconduct. The Complainant will be provided with available resources and referrals for medical
treatment at local hospitals and trauma centers. The Complainant will also be advised of the right to an advisor of his or her
choice to accompany them to all meetings during the investigation.
Listed below is a summary of the disclosures the Title IX Coordinator is required to discuss with the Complainant and
the Respondent:
The right to be notified of the timeframe for the major stages of the investigation;
The right to present witnesses and evidence;
The Title IX Coordinator will inform the Respondent that an investigation is being commenced and the allegations
of the Complainant. If there is a written complaint, the Respondent will be provided with a copy of the complaint, unless
circumstances warrant otherwise;
If the alleged Respondent is allowed to have a lawyer; the Complainant has the right to have one too;
Both parties are offered the opportunity to submit questions (in writing) of the other party and/or witnesses to the
Adjudicator. However, the Adjudicator reserves the right to decline to ask the questions submitted;
Both parties will be informed that the College prohibits retaliation in any form against any person who reported the allega-
tion of Sexual Misconduct or participates in the investigative proceedings. Reports of retaliation will be investigated and
individual(s) involved will be subject to disciplinary action;
The College uses the Preponderance-of-the Evidence Standard of Proof to adjudicate the complaint. The College cannot
use a Higher Standard of Proof;
The right to be given periodic status updates; to be notified in writing of the outcome of the complaint and any appeal,
including any sanctions directed to each party;
Inform both parties of their right to appeal the outcome of the complaint;
Each party has the right to have the proceedings documented, which may include written findings of fact, transcript, or
audio recordings;
The Complainant has the right not to “work it out” with the Respondent in mediation. Mediation is not appropriate in cases
involving Sexual Assault.
DOWNTOWN BROOKLYN
151 Lawrence Street
Brooklyn, NY 11201
Tel: 718 - 522-9073
DANIA BEACH
225 E Dania Beach Blvd, Suite 120
Dania Beach, FL 33004
Tel: 786-279-1740
HIALEAH
530 West 49th Street
Hialeah, FL 33012
Tel: 786-279-2643
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel: 212-672-6450
The Title IX Coordinator will conduct a preliminary investigation to assess whether this Policy or the Student Code of Conduct
may have been violated. If the Title IX Coordinator determines that there was a finding of Sexual Misconduct, the Title IX
Coordinator will notify the Respondent in writing that a complaint has been filed and provide the factual allegations concerning
the alleged violation, and possible sanctions.
The Title IX Coordinator will schedule a meeting with the Respondent, within a reasonable amount of time, and ensure the
Respondent is provided with a written explanation of all available resources and options, and is offered the opportunity to
discuss those resources and options.
Wherever possible, simultaneous notification will be given to both parties (Complainant and Respondent) either by personal
delivery; overnight mail with signature requirement; certified mail with return receipt to the address in ASA College’s records;
and/or by email to the Complainant’s and Respondent’s ASA College’s email accounts. The notice shall contain: (1) the date,
approximate time, and location of the alleged violation; (2) a description of the factual allegations; and (3) a summary of poten-
tial sanctions associated with the alleged violation.
The notice shall inform the Complainant and the Respondent of the right to bring an advisor to meetings and ensure there is a
clear understanding that the role of the advisor is to support and advise, not to speak on the behalf of the Complainant or
Respondent or to take any action that may interfere with the integrity and process of the investigation.
The Investigator will interview the parties about the complaint, as well as any witnesses who have been identified. The Investi-
gator will ask the parties for any documentary, electronic, or other evidence related to the complaint that they want to offer.
Prior sexual history with persons other than the charged party in a disciplinary proceeding is not considered evidence and will
be excluded. Also, the mental health diagnosis and/or treatment of the parties will be excluded from the decision stage of the
disciplinary process that determines responsibility. However, past findings (especially repeated offenders) of Domestic
Violence, Dating Violence, Stalking or Sexual Assault may be admissible when determining sanctions. All individuals who are
interviewed shall be advised to maintain privacy of the investigation process and not to disclose any information related to the
complaint unless necessary during the complaint process. Maintaining privacy is important to preserve the integrity of the
investigation and deter retaliation.
Summary of the preliminary investigation:
Page 4 of 4
It is generally the Complainant’s decision whether to file a complaint or to continue with any form of resolution. If the Com-
plainant elects to initiate a formal complaint against another person or group of persons, a Sexual Misconduct Report Form is
filed with the Title IX Coordinator, and an investigation is conducted.
Please provide the information requested and deliver the completed form to:
TITLE IX COORDINATORS
Dr. Jayne Weinberger Jennifer Ross, JD / Esq.
Chair, Ophthalmic Dispensing /
Title IX Coordinator
Faculty, Legal Studies Division /
ADA / Title IX Coordinator
ASA College - New York ASA College - Miami
1293 Broadway, Room 602 225 East Dania Beach Blvd., Room 208
New York, NY 10001 Dania Beach, Florida 33004
212-672-6450 (ext.1431) 786-279-1741 (ext.4055)
jweinberger@asa.edu jross@asa.edu
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