Sexual Misconduct Reporting Form

NOTE: If you have an immediate health or safety concern, please call 911.

Per Board Policy 3.5: Policy Prohibiting Sexual Misconduct, incidents of Sexual Harassment and Sexual Violence are Prohibited.

What to Report: Please use this form to report incidents of sexual harassment, sexual assault and other non-consensual sexual contact, sexual exploitation, dating violence, domestic violence and sex-based stalking.

Please contact the Equal Opportunity Office at CivilrightsEEOAA@western.edu to make reports of discrimination based on a protected category, including sex discrimination and pregnancy discrimination.

If you have any questions prior to completing this form, please contact the Title IX Coordinator at TIXadministrator@western.edu to consult. Individuals who are not responsible employees may submit this form anonymously. Depending on the amount of information included in the report, the University may be limited in its ability to respond to the concern.

Individuals who are designated as Responsible Employees (Board Policy 3.5.IV.C.2) who are filling out this form as part of their reporting obligations must fill in all known information and cannot remain anonymous.

Your name or write “anonymous” if you want to remain anonymous:
Your role at the University:
Your phone number (optional):
Your email address (optional):
I am reporting potential:
I am also reporting a potential (optional):
Approximate date of incident:
Location of incident:
Complainant Name(s) — The person who experienced the alleged behavior. Write "Anonymous" to remain anonymous. Responsible Employees per Board Policy 3.5 must report all known information.
Respondent Name(s) - A respondent is the person accused of the alleged behavior.
Witness Name(s) - Witnesses can be individuals who directly witnessed the incident or individuals who have information about the incident through another means.
Please provide a concise description of the incident or concern, including who was involved, what happened, where it took place, and when it occurred.
Is there any additional information you would like the Restorative Justice and Title IX Office to know? (If you are reporting as an employee, please remember to be objective):
To your knowledge, have Campus Security Services been notified about this incident?
Date created

9/9/2026 21:30

Sexual Misconduct Reporting Form

Incident Details