Bias, Harassment/Discrimination & Title IX Reporting

Please enter your contact information:

Phone(Required)

Email(Required)

I am a:(Required)

When did you become aware of this incident?

The day or time you received the information

If you know when the incident occurred, please list the date and time below:

If known, please indicate the specific location where the incident occurred (i.e. room number):

Please describe the incident in as much detail as possible:(Required)

Yes (please explain):(Required)

Unsure (please explain)(Required)

Please provide the name(s) of the individual(s) accused of committing the act of bias, discrimination/harassment, or sexual discrimination (including sexual violence and/or harassment) in this situation:(Required)

How is the accused individual(s) affiliated with Bellin College? (For example: student, employee, visitor/guest, no campus role, or unknown)(Required)

Other (please explain)(Required)

Are there any other individuals to whom the victim/complainant has reported the incident? If so, please list the names of those individuals below:

How would you like to see the issue resolved (realizing Title IX complaints may require an investigation)?

Please share any relevant documents or photos:

Drop files here or

Max. file size: 50 MB.

How would you like to be contacted?(Required)

Victim/Complainant Signature(Required)

Type name here

Name of Person who Assisted you with filling out this form (if applicable):

BC Family

Visitors

BC Family

Visitors

Bias, Harassment/Discrimination & Title IX Reporting

Bias, Harassment/Discrimination, and Title IX Complaint Form

Please enter your contact information:

When did you become aware of this incident?

If you know when the incident occurred, please list the date and time below:

BC Family

Visitors

Bias, Harassment/Discrimination & Title IX Reporting

Bias, Harassment/Discrimination, and Title IX Complaint Form

Please enter your contact information:

When did you become aware of this incident?

If you know when the incident occurred, please list the date and time below:

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