Jenzabar University

Converse is required by law to investigate all alleged prohibited conduct under the College's Sexual and Gender-Based Misconduct Policy. Any information disclosed may trigger an investigation. As a reminder, employees of the College are responsible employees and must report any prohibited conduct that is disclosed to them by students or colleagues. Employees may complete all fields in this form or contact the Title IX Coordinator or any other Deputy Coordinator within 24 hours of disclosed prohibited conduct. To those anonymously completing this form, please provide as much information as you are willing to provide.

Full Name

Your Position/Title

Your Email Address

Your Phone Number

If this is a discrimination or harassment complaint, please indicate the protected status(es) that is/are the basis of the alleged behavior:

Date and Time of Incident

Location of Incident

Specific Location

Please list all parties involved (excluding yourself, if reporting anonymously) and provide as much information as possible about those who played any role in the alleged prohibited conduct.

Roles in which the parties may be involved include the following:

• Complainant: Individual who allegedly experienced sexual or
  gender-based misconduct while a student or College employee
• Victim: Alleged victim but is not considered a Complainant
• Respondent: Individual who may have violated the College's Sexual and Gender-Based Misconduct Policy
• Witness: Individual(s) (excluding yourself, if reporting anonymously) who observed the alleged behavior and can provide additional information
• Person of Concern: Converse community member who is exhibiting
  concerning behavior but is not considered a Respondent.
  

Involved Parties:

Please provide a detailed description using *specific, concise, and objective* language. Describe, in as much detail as possible, the specific behaviors observed, including words, phrases, and actions, as well as dates and times. If the involved party used profanity, made threats, or spoke of harming self or others, indicate the specific terms and language used. If the involved party was loud or disruptive, indicate any behaviors associated with the disruption, and describe any injury or damage to individuals or property. Include names of College personnel you contacted and actions taken, if any.

Description:

Describe the impact the behavior has had on you:

Have you taken any action to stop the behavior?

What actions have you taken and what was the outcome?

Please add any additional information that supports your complaint:

File Upload

Use the buttons below to upload any documents or photos related to this incident. If you would like to submit more you may email TitleIX@converse.edu.

Click to attach document/photo.

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