Title IX Incident Report Form

Your Information

Information about the person filling out this form.

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Your full name (required):

Your position/title (required):

Your phone number:

Your email address (USF):

Email address must be of a valid format.

Date of incident(Required):

This field is required.

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If date is unknown, please select today's date and indicate timeframe (if known) in description box

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

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Please include all known location(s). If exact location is unknown, please type

Involved Parties

INSTRUCTIONS - PLEASE READ CAREFULLY!!

List the individuals involved (excluding yourself), providing as much information as you know.

DO NOT LEAVE COMPLAINANT OR RESPONDENT FIELDS BLANK. If you are a Responsible Employee (anyone who teaches or supervises even one USF student or employee in any capacity), you are required to include the name(s) of any parties that were shared with you so that we can provide them resources and support measures. If you do not know the name of one or both of the parties, please write "Unknown".

Step 1: Fill out the information for Complainant(s) (the individual[s] alleged to have experienced the incident[s]). If multiple parties are named as Complainants, please click "add another party" and include information for all known Complainants.

Step 2: Click "add another party". Fill out the information for Respondent(s) (the accused individual[s]). If multiple parties are named as Respondents, please click "add another party" and include information for all known Respondents.

Step 3: Click "add another party". Fill out the information for any witnesses, if applicable.

Name or Organization

Select Role

U Number

Phone number

Email address (USF email preferred)

Residence Hall/Address

Questions

From which campus of USF are you reporting?(Required) This field is required.

Is this a report of relationship (dating or domestic) violence?(Required) This field is required.

Is the person who experienced this incident safe to contact? (Please ask in cases of Relationship Violence to ensure the perpetrator does not have access to their forms of contact, select "N/A" if not Relationship Violence)(Required) This field is required.

If someone other than the Complainant reported to you (third-party report), please provide the Name and USF email address of the third party who reported to you. Leave blank if not a third-party report. This field is required.

Please provide a brief description of the reported incident and how it was disclosed to you. Please do not conduct any inquiry or investigation into the matter. You only need to provide what they disclosed. Did they disclose in person, by email, or by phone? What did they disclose that prompted you to complete this form? If a specific date of the incident is not known, what timeframe did the discloser provide, if any? This should only be brief summary.(Required) This field is required.

Did you provide resources to the victim?(Required)

Title IX Victim Advocacy Police Counseling Medical Crisis Center Domestic Violence Shelter Other No resources were provided

You must make at least one selection.

List all other actions taken, such as notifying a supervisor, HR, submitting a SOCAT or SCED referral, reporting to police, etc.(Required) This field is required.

Supporting Documentation

If you have any additional information you wish to submit via attachment, please do so here. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Your Information

Involved Parties

Questions

Supporting Documentation

Submission