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  Title IX Incident Report Form

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INCIDENT REPORT FORM FOR VIOLATIONS OF POLICY ON NONDISCRIMINATION, HARASSMENT (INCLUDING SEXUAL HARASSMENT), DISABILITY ACCOMMODATION OR RETALIATION

This form may be completed by any member of the DSU community who has experienced or otherwise become aware of an incident that may constitute a violation of the University’s Policy on Equal Opportunity, Harassment and Nondiscrimination.  The person making the report, as well as the victim/survivor, may identify themselves or remain anonymous.

To report a potential violation, please print and complete this form, and send it to our Title IX Coordinator, Dr. Stacy L. Downing, Assistant VP of Student Affairs, MLK Student Center, Suite 317.

If you have any questions or concerns, call 302.857.6300.

 

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(including details on any injuries or other harm suffered by the victim/survivor)
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Information about the Reporter

     

Information about the Victim/Survivor

(if different from the above)

     

Information about the Offender

     

Information about the Conduct