Important Information Reporting Options This form provides official notice to Appalachian State University of an issue of alleged Discrimination, Harassment, and/or Retailation. Per Policy 110, this online form is a disclosure of information by a person alleging the occurrence of discrimination, harassment or retaliation prohibited by University Policy. Upon the forms submission, it is assessed by Appalachian State University to determine the most appopriate means through which the concern may be addressed. Please be advised filing a report may initiate or result in a formal complaint either by the Reporting Party or the University. Please note: Information provided related to sexual violence, harm to self, or imminent harm to others may require a formal response due to the University’s obligations to uphold Title IX, Clery Act, and related laws. Would you like to report a concern for intimate parter violence, such as sexual assault, relationship violence or stalking? If your concern is in regards to intimate partner violence, please contact the Office of Title IX Compliance and/or complete their online reporting form.Would you like to report a crime to the Appalachian State University Police Department? If this is an emergency, please call 828 262 8000 (emergency) or 911.If this is a non-emergency, please call 828 262 2150 (non-emergency).You may also report a crime to Appalachian State University Police online. Would you like to report an allegation of student misconduct? If your concern is in regards to the alleged misconduct of an Appalachian student, such as vandalism, plagarism, and more, please contact the Office of Student Conduct and/or report the incident online,Would you like to report a concern for the well-being of an Appalachian student? If your concern is about the emotional well-being of a student, including concerns for adjustment to college life, grief, or more, please feel encouraged to contact the Office of the Dean of Students. Resources Counseling & Psychological Services - Confidential Support for Students828-262-3180Counseling for Faculty & Staff - Confidential Support for Employees828-262-4951 Your Contact Information Please provide us with your name and contact information. First Name While identifying information is not required, anonymous reporting limits the University's ability to respond to complaints. Last Name While identifying information is not required, anonymous reporting limits the University's ability to respond to complaints. Email Phone Number How would you like the University to respond to your concern? * - Select -I would like for someone to contact me.This is for information only. Date of Incident, if known MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year2015201620172018201920202021 Year Time of Incident, if known Hour123456789101112 Hour :Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Minute am pm Is the incident isolated or ongoing? Isolated Ongoing Where did the incident occur? * On campus Off of campus Online On Campus Locations * - Select -Appalachian HeightsAppalachian Panhellenic Hall (APH)Belk HallBowie HallCannon HallColtrane HallCone HallDoughton HallEast HallEggers HallFrank HallGardner HallHoey HallJustice HallLiving Learning Center (LLC)Lovill HallMountaineer HallNewland HallSummit HallWhite HallBelk LibraryCollege Street Parking DeckHolmes Convocation CenterKidd Brewer StadiumPlemmons Student Union and SolariumQuinn Recreation CenterRivers Street Parking DeckSanford MallState Farm ParkingOther... On Campus Locations Other... What was your role? * I experienced the incident I witnessed the incident This incident was reported to me. Are you a responsible employee? * Yes No I'm unsure A Responsible Employee is an employee who has the authority to address sexual violence or who has been given the duty of reporting. It may also include an employee who a student reasonably believes has this duty and authority. All faculty members are responsible employees. If you are unsure of your specific role, check with your Title IX Coordinator or speak with your supervisor to understand your responsibilities. Please describe the nature of your concern * Harassment Discrimination Retaliation Not sure Other... Please describe the nature of your concern Other... My concern relates to: * Race Color Religion National Origin Sex/ Pregnancy/ Gender Age Disability Gender Expression/Gender Identity Genetic Information Political Affiliation Veteran Status Sexual Orientation Other... My concern relates to: Other... Involved Parties Please list the individuals involved and what role they played. An individual listed as Respondent is the party who may have violated policy. Ones listed as the Reporting Party are the individual to whom the misconduct was directed; ones listed as a Witness are an observer to the incident. Name Select Role Reporting Party Respondent Witness Email Phone Name Select Role Reporting Party Respondent Witness Phone Email Name Select Role Reporting Party Respondent Witness Phone Email Please describe the incident. * If you would you like to provide files related to the incident, such as screenshots or emails, please send them to complaints@appstate.edu. Has this incident been reported in the past? * Yes No Leave this field blank Submit
