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 Additional Information Would you like to report 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).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. Against a student: Contact the Office of Student Conduct at 828 262 2704 or studentconduct@appstate.eduAgainst a staff or faculty member: Contact the Office of Title IX Compliance at 828 262 2144 or baerap@appstate.eduResources Counseling CenterInitial Consultation HoursMonday - Friday 8:30-11:00 a.m. & 1:00-4:00 p.m.828-262-3180Counseling for Faculty & StaffMonday - Friday 8:00 a.m. - 5:00 p.m.400 University Hall828-262-4951 Leave this field blank Submit
