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Discrimination, Harassment, Title IX, and Retaliation Report Form


This form provides preliminary information to the Equal Opportunity and Equity unit of the Office for Institutional Equity and Diversity to assist in resolving violations of NC State University Policy 04.25.05: Equal Opportunity, Non-Discrimination and Affirmative Action and NC State University Policy 04.25.07: Title IX Sexual Harassment. Please complete this form to the best of your knowledge.

Upon receipt of this form, someone from the Equal Opportunity and Equity unit may contact you if additional information is needed.

Regardless of the nature of your report, NC State University will ensure that your information is forwarded to the office with responsibility for investigating and addressing complaints, reports, or concerns as appropriate, based on the information you have provided.

The information you provide will be kept confidential to the extent permitted by law.

If you have questions, please contact our office at equalopportunity@ncsu.edu or by phone at 919.513.0574.

If you are completing this form as a Designated Offical or Responsible Employee, please ensure you provide your name and contact information as well as identifying information regarding the involved parties. Note: A Responsible Employee Report is required from those who have been given the duty of reporting incidents of sex discrimination or any other misconduct to the Title IX Coordinator or other appropriate school designee.

This Reporting Form is NOT a 911 or Emergency Service. Do not use this site to report events presenting an immediate threat to life or property. If you require emergency assistance, please contact NC State Police at 919.515.3000 or dial 911.

Reporter Information

NOTE: If you wish to submit a complaint for yourself anonymously and you are not a Responsible Employee, you may omit your contact information or deliver or send your complaint to:

Office for Institutional Equity and Diversity
231 Winslow Hall, Box 7530
NC State University
Raleigh, NC 27695-7530
 
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Name of person completing this report
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Student, Faculty, Staff, Alumni, Parent, Visitor, etc
Email address must be of a valid format.
This field is required.
This field is required.
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Identify the affiliation of the Respondent
This field is required.
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What date did the concern occur?
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At what time did the concern occur?
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Address, Room Number, or Other Details

Involved Parties

Please provide the following information about the individual(s) you believe discriminated against you, harassed you, or retaliated against you. This may include incidents of sexual harassment, sexual violence, relationship violence, and stalking.

If you are completing this as a Responsible Employee, please indicate all involved parties that were shared with you and their respective roles. Please indicate all involved parties. If you do not have all of the information, you may leave fields blank.

  • Complainant: the individual to whom the misconduct was directed
  • Respondent: the individual who may have violated University policy;
  • Witness: the individual who observed the alleged behavior and can provide additional information
Involved party 1

Incident Specific Information

Please complete the information below to the best of your ability.

Are you reporting this incident for yourself or for another person?(Required)
This field is required.
What is the nature of this report? (Please select all that apply.)(Required)
You must make at least one selection.
Do you feel this behavior happened because of: (Please select all that apply.)(Required)
You must make at least one selection.
This field is required.
This field is required.
Please identify if you are completing this form as a Responsible Employee or Designated Official. As referenced and hyperlined above, Responsible Employees and Designated Officials have the duty to report incidences of sex discrimination or any other misconduct to the Title IX Coordinator.(Required)
This field is required.
By completing and submitting this form, I agree that I was provided access to NC State University Policy 04.25.05: Equal Opportunity, Non-Discrimination, and Affirmative Action and NC State University Policy 04.25.07: Title IX Sexual Harassment Policy (hyperlinked above) and their related procedures.(Required)
This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Select copy recipients

(For police use only): If other departments or individuals should receive a copy of this report, please select them below:
(For police use only): If other departments or individuals should receive a copy of this report, please select them below:

Submission