Sexual Misconduct Reporting Form This form is intended to be used to report incidents of sexual misconduct or assault to Frank Phillips College (FPC) when either the victim or the person being accused is an FPC student or employee. My Information (Reporter)Status(Required)Select "Anonymous" if you wish to report anonymously. It is important to know that the College's ability to address anonymous reports is limited. If you are an Official Required to Report, you may not report anonymously. Student Faculty or Staff (Required to Report) Anonymous Other Define Other:(Required)Name(Required) First Last Phone(Required)Email(Required) Your preferred method of contactIf you wish to remain anonymous but want to provide contact information, you should use a non-college affiliated email address that does not have your name or other identifying information. If you choose not to provide contact information, the college may be limited in its ability to take action on your report. Are you the person directly impacted?(Required) Yes No Who is the person directly impacted? First Last What is their status?(Required) Student Faculty or Staff (Required to Report) Other Define Other:(Required) Incident InformationDate of Incident(Required) MM slash DD slash YYYY Time of Incident(Required) Hours : Minutes AM PM AM/PM Location of Incident(Required) Incident occurred On Campus Incident occurred Off Campus Campus Location(Required)Please SelectBorger CampusDalhart - Rahll CampusPerryton - Allen CampusSpecific location information(Required)Specific location information(Required)Indicate specific building, room, or outside area.Incident SpecificsPlease select any and all conduct that applies to include physical, verbal, written, audible, visual and electronic activity. The definitions below are only examples that do not necessarily reflect all prohibited conduct and are not intended to be legal definitions of a crime or act. Conduct Type Sexual Harassment - unwelcome conduct of a sexual nature and/or to one's gender, including but not limited to unwelcome sexual advances, requests for sexual favors, sexual violence, being singled out for adverse conduct due to one's gender, and other verbal or nonverbal conduct of a sexual or gender-related nature. Sexual Violence - physical sexual acts perpetrated against a person's will or when a person is incapable of giving consent due to the victim's use of drugs or alcohol or other disability, including age. Sexual violence includes but is not limited to rape, sexual assault, sexual battery, fondling, incest or any other behavior used to obtain sexual gratification against another's will or at the expense of another. Dating Violence - violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim. Domestic Violence - includes felony or misdemeanor crimes of violence committed by a current or former spouse of the victim, or by a person with whom the victim shares a child in common, or by a person who is cohabitating with, or has cohabitated with the victim as a spouse, or by a person similarly situated to a spouse of a victim under the domestic or family violence laws of the jurisdiction receiving grant monies, or by any other person against an adult or youth victim who is protected from that person's acts under the domestic or family violence laws of the jurisdiction. Sexual Coercion - the use of manipulation or threat to force someone to have sex. Stalking - the engaging in a course of conduct directed at a specific person that would cause a reasonable person to fear for his or her safety or the safety of others, or to suffer substantial emotional distress. Sexual Exploitation - taking non-consensual or abusive sexual advantage of another for one's own advantage or benefit, or to benefit or advantage anyone other than the person being exploited, including but not limited to, non-consensual video or audio-taping of sexual activity or undetected viewing of another's sexual activity. Sexual Harassment Sexual Violence Dating Violence Domestic Violence Sexual Coercion Stalking Sexual Exploitation Other Please provide a narrative description of the information you seek to report.(Required)You may include what happened, why you are reporting it, any actions you have already taken in response to what happened, or other resources you have been offered or are utilizing to. If the incident(s) occurred in association with a specific department, program, student organization or group, or other FPC-affiliated organization, include that information. Are there any witnesses that you are aware of?(Required) Yes No Please provide witness information:(Required)Include the name and any contact information (phone &/or email) you have for each witness.Has law enforcement been contacted about this report?(Required) Yes No I don't know If known, please provide case number Supportive MeasuresPlease select any and all supportive measures you would like to request. Supportive measures are designed to preserve equitable access to Frank Phillips College's educational programs and activities. Supportive Measures Requested: No Contact Order Faculty Notification On-Campus Counseling Off-Campus Counseling Work Schedule Adjustment Academic Adjustment Residence Hall Relocation Facility Access Plan SM Req cont. Campus Security Escort Medical Care Victim Advocate Outreach Assistance Reporting to Law Enforcement Academic Withdrawal/LOA Academic Withdrawal (full) Legal Support Information Visa/Immigration Information Other: Define Other(Required) ResolutionResolution Requested:(Required) No Action at this time Informal Resolution Formal Resolution (Investigation and Hearing) Verification Statement(Required)I certify that the information provided in this form is true, correct, and complete to the best of my knowledge. I understand and agree with the above statement.
