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SEXUAL MISCONDUCT REPORTING FORM PLEASE READ CAREFULLY BEFORE (Eastern Florida State College)

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SEXUAL MISCONDUCT REPORTING FORM
PLEASE READ CAREFULLY BEFORE USING THIS FORM
DO NOT USE THIS FORM TO REPORT AN IMMEDIATE OR ONGOING THREAT. CALL 911 THEN CAMPUS SECURITY.
Why use this form? Eastern Florida State College takes very seriously its obligations under Title IX of the
Education Amendments of 1972. Title IX prohibits discrimination on the basis of sex in any federally funded education
program or activity. Sexual Misconduct is a form of sex discrimination prohibited by Title IX, and when the College is
made aware of allegations involving Sexual Misconduct, it must immediately investigate what happened, and as
appropriate, take prompt and effective action to stop the Sexual Misconduct, prevent its recurrence, and remedy its effects.
Who can use this form? Use this form if you are a student, employee, faculty, or other member of the College
community wishing to report to the College an incident of Sexual Misconduct that you personally endured or witnessed.
Is the information on this form confidential? No. Confidentiality means that information provided by an individual
cannot be revealed to anyone else without the express permission of the individual. Because of the College’s
obligations under Title IX and other laws, the information provided in this form is not confidential. A person who
reports Sexual Misconduct may request that his or her identity be kept confidential, and such a request will
be considered by the College in determining an appropriate response. However, there are situations where the College
may have to override a person's request for confidentiality in order to meet its legal obligations.
Will the information on this form be kept private? Yes. The information provided in this form will only be shared with only
those individuals who are involved the review, investigation, or resolution of the report. While not bound by
confidentiality, College officials will be discreet and respect the privacy of anyone involved in the process to the greatest extent
possible.
Can I use this form to report anonymously? No. DO NOT USE THIS FORM if you wish to report Sexual Misconduct
anonymously. Instead, use the form entitled “Anonymous Reporting Form”, which is available on the College
website. Anonymous reports will be investigated, however, the College’s response may be limited depending on
the information provided.
How do I submit this form to the College? When you have completed this form, you may submit it to any of the
following College officials:
Mark Renkens
Title IX Compliance Coordinator
Melbourne Campus, Bldg. 10, Room 215
Phone: (321) 433-7180
Fax: (321) 433-5026
E-Mail: renkensm@easternflorida.edu
Darla Ferguson
AVP H.R. and Chief Equity & Diversity
Cocoa Campus, Bldg. 2, Room 113
Phone: (321) 433-7080
Fax: (321) 433-7685
E-Mail: fergusond@easternflorida.edu
Joe Ambrose
Chief of Security
Melbourne Campus, Bldg. 8, Room 201
Phone: (321) 433-7007
Fax: (321) 433-5026
E-Mail: ambrosej@easternflorida.edu
*In addition, please note that you may submit this form after regular business hours or when the College is closed to any Campus
Security office.
What happens after this form is submitted? Upon receipt, appropriate College officials will review the information
provided and conduct a preliminary inquiry into the reported allegations. The person(s) identified in this form may be
contacted to discuss the information provided and determine appropriate next steps.
A note about the terms “Victim” and “Survivor”: For the sake of brevity, this form uses the word “Victim” to describe the
person who endured the incident of Sexual Misconduct. By use of this word, the College intends no disrespect to any
Survivor.
1
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SEXUAL MISCONDUCT REPORTING FORM
Reporting Party (person making the report)
Are you: The Victim
A Third Party/Witness
If you are a Third Party, does the
Victim know you are making this
report? Yes No N/A
Are you a: Student Employee
Faculty Other_____________
First Name:
Last Name:
Address:
City:
Zip:
Phone Number:
E-Mail Address:
Gender:
Race:
Age:
Victim (if not the same person as the Reporting Party)
Is the Victim a: Student Employee Faculty
Other______________________________________
Victim’s Age:
First Name:
Last Name:
Address:
City:
Zip:
Phone Number:
E-Mail Address:
Gender:
Race:
Age:
Law Enforcement
Was the incident reported to any law enforcement agency? If so, which agency?
Does the Victim want the incident reported to law enforcement? Yes No Unknown
Does the Victim request assistance with reporting the incident to law enforcement? Yes No Unknown
Other Reports
Has the Victim reported the incident to anyone else? Yes No Unknown (if the answer is “yes” please list
the names and contact information below)
Incident
Date of Incident:
Time of Incident:
Location of incident (if incident occurred on EFSC property, identify which campus, building, parking lot, etc.):
3
Description of incident:
Responding Party (information about the accused; use separate pages if multiple persons accused)
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone Number:
E-Mail Address:
Gender:
Race:
Age:
Is this person a student, employee, or faculty of EFSC? Yes No Unknown
Is this person an acquaintance of the Victim? Yes No Unknown (if the answer is “yes” describe the
relationship between the Responding Party and the Victim)
Witnesses (information about any witnesses; use separate pages if multiple witnesses)
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone Number:
E-Mail Address:
Age of the Witness:
Is this person a student, employee, or faculty of EFSC? Yes No Unknown
Medical Treatment
Did the Victim receive any medical treatment after the incident? Yes No Unknown (if the answer is
“yes” please indicate when and where the Victim received treatment below)
4
Evidence
Did the Victim preserve any evidence involving the incident? Yes No Unknown (if the answer is “yes”
please describe the evidence and identify the person(s) who have current possession of it below)
Alcohol or Drugs
Was either party under the influence of alcohol or other drugs at the time of the incident? Yes No
Unknown (if the answer is “yes” please describe the nature and extent of influence below)
Weapons
Were any weapons used during the incident? Yes No Unknown (if the answer is “yes” please describe the
weapons below)
Hate Crime Assessment
Is there any evidence that the incident was motivated by the Victim’s race, gender, gender identity, religion,
sexual orientation, ethnicity, national origin, or disability? Yes No Unknown (if the answer is “yes” please
describe which category of bias and supporting evidence below)
Threat Assessment
Is there reason to believe this incident represents a present or continuing threat of harm or danger to the Victim
or other member(s) of the College community? Yes No Unknown (if the answer is “yes” please describe
the threat below)
Resource Guide
Has the Victim received a copy of the EFSC Sexual Misconduct Resource Guide? Yes No (if the answer is
“no”, it is strongly encouraged that the Victim read the Resource Guide, which is available on the College website)
5
Immediate Accommodations
At this time, does the Victim request any immediate accommodations from EFSC, such as a campus no-contact
order, or changes to academic, living, transportation, and/or working situations? Yes No Unknown (if
the answer is “yes” please describe the requests below)
Signature of Reporting Party
I affirm that the information provided above is true and correct to the best of my knowledge.
Date: ___________________ By: __________________________________________
Reporting Party
-------------------------------------------FOR ADMINISTRATIVE USE ONLY---------------------------------------------------
DATE REPORT RECEIVED:
TIME REPORT WAS RECEIVED:
NAME AND CONTACT INFORMATION OF PERSON RECEIVING REPORT:
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Completed 15 August 2020

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