Title IX Reporting Form

Background Information

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Your full name:

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You may submit anonymously, but doing so will limit the College's ability to address your report.

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

How were you affected?(Required):

This field is required.

Date of incident(Required):

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If there were multiple dates, please select the most recent one and provide more information below.

Time of incident:

Location of incident(Required):

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If there were multiple locations, please select the most recent one and describe additional below.

Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide.

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Residence Hall/Address

Questions

Please briefly summarize the incident/concern using specific, concise, and objective language. Our office will follow up to obtain additional information.(Required) This field is required.

Have you already reported this to anyone else on or off campus? If you have, please include a name.(Required) This field is required.

If you contacted any of the following resources, please select them below.

Security EMS BRAVE Administrator on Duty Counseling Services Health Services Red Hook Police New York State Police Other Law Enforcement

You must make at least one selection.

What actions, if any, would you like the College to take in response to this report? This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 1GB maximum total size. Attachments require time to upload, so please be patient after submitting this form. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission