3. Reporter's Phone
Complainant (Victim/Survivor) Contact Information
5. Is the Complainant the same as the Reporter?
Title IX Accessible Report
A time sensitive incident may warrant an immediate response. If you need immediate
response, please call 911 to receive medical support. If you prefer not to use the online
reporting form or encounter accessibility problems with the form, please call the Title IX office
for assistance at 314-889-1416.
Anonymous Reporting
An individual may report an incident without disclosing his/ her name, identifying the
respondent or requesting any action. Please note that choosing to make an anonymous report
can significantly limit the ability of the university to respond. (Reports that are made
anonymously or by third parties may not initiate the formal complaint system.)
Responsible Employees
Responsible employees must immediately report allegations or disclosures of sexual
misconduct involving students to the Title IX office. Because the definition of responsible
employee is so broad, you should consider yourself a responsible employee unless you qualify
as a confidential resource. (Confidential resources include the Counseling and Wellness
department.)
Reporter Contact Information
1. Reporter’s Name
While reporters can submit reports anonymously, we encourage them to provide contact
information in case more details are needed. (Reports that are made anonymously or by
third parties may not initiate the formal complaint system.)
2. Reporter's Email
4. Reporter's Affiliation
Yes
No
Faculty
6. Complainant's Name
7. Complainant’s Email
8. Complainant’s Phone
9. Complainant’s Affiliation
Respondent Name (Alleged to have violated the University Title IX policy or Sexual Misconduct Policy)
10. Respondent's Name
11. Respondent’s Affiliation
12. Other Individuals Involved and Witnesses
Please list any other involved individuals (including additional respondents, complainants
and witnesses). Please include their name, contact information and role (such as
witness), along with any other type of information.
Sex-Based Discrimination, Harassment or Misconduct (please
check all that apply)
13. Types of misconduct, discrimination or harassment
Sexual Assault
Dating Violence of Relationship Violence
Domestic Violence
S
talking
Sexual Harassment
Not Applicable
Unknown / Not Sure
Student
Student
Time, Location and Description of Concern
14. Date and time incident occurred. Provide as much information as you can (month, day, year, time,
semester) about when the incident occurred. If you do not have any information about when the incident
occurred, please write unknown.
15. Location information. Please identify if the incident occurred on campus, in space rented or leased
by the university or in a location off campus not managed by the university. If known, please include
building name, room number, address and street name.
16. Incident description. (Please describe what happened)
For Title IX Coordinator contact information please visit our website. If you have any
questions, please contact the Title IX Coordinator at 314-889-1416.
After this report has been completed and saved as a PDF, please email to Carla Hickman at
chickman@fontbonne.edu.