Sexual Misconduct and Title IX Self-Report

Please complete the requested information to the best of your abilities.

(*) indicates a required field

Important Notes:

Survivor Information
You can write in "anonymous" if you do not want to disclose your name. (see 'Important Notes' above)
*Phone number:
*Email address:
*Please select your primary status:  St. Norbert College Undergraduate Student
 St. Norbert College Graduate Student
St. Norbert College Faculty
St. Norbert College Staff
Other, please specify:
Gender:  Male
 Another identity, please specify: 
Date of alleged violation:
Time of alleged violation:
Responsible Individual Information
Responsible individual refers to the individual responsible for the sexual misconduct or Title IX violation/incident, otherwise known as the alleged perpetrator.
*Name (if known):
Phone number:
Gender:  Male
Another identity, please specify: 
*Please select their primary status:  St. Norbert College Undergraduate Student
 St. Norbert College Graduate Student
 St. Norbert College Faculty
 St. Norbert College Staff
Other, please specify:
Violation/Incident Information
*Nature of the violation/incident. Please check all that apply:

The Sexual and Gender Harassment/Discrimination Policy has full descriptions for the below terms.

Hover over term for brief descriptions. 
Sexual Harassment
Sexual Violence
Dating or Domestic Violence
Gender-Based Misconduct
Other, please specify:

*Description of violation/incident:

Describe your knowledge of the sexual misconduct or Title IX violation/incident to the best of your abilities.
*Location at which the alleged violation/concern took place: On Campus, please specify:
Off Campus, please specify:
Have you or will you report this incident to law enforcement or St. Norbert College Campus Safety? Yes / SNC Campus Safety
 Yes / Local Police Department
Resources you have received and/or contact you have made at this time: Residential life staff
SNC Health and Wellness Services
Sexual Assault Center of Green Bay
SNC Campus Safety
SNC Counseling and Psychological Services
De Pere Police Department
  I understand that St. Norbert College takes all possible sexual misconduct or Title IX violations/incidents very seriously. By submitting this form (which is received by the Title IX Coordinator), I am indicating that I understand and agree that the information I have provided may be disclosed when and if necessary to ensure the safety of the members of the college. However, any information that is shared will be done with the utmost respect for privacy and sensitivity. In lieu of your signature, the submission of this form will indicate your agreement with this declaration.
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