Sexual and Gender-based Harassment, Misconduct, and Violence Report

Background Information

All faculty members, staff members, and administrators are expected to report any disclosures that involve allegations of sexual and gender-based harassment, misconduct or violence. The exceptions for mandatory reporting are those designated as confidential campus resources (e.g., Health and Counseling Center staff, Campus Ministry staff, Priests serving on campus, and those designated as confidential resources).

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Type of Incident(Required):

This field is required.

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Please describe the category of alleged incident of sexual or gender-based harassment or violence

UP affiliation of victim(Required):

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This designation will route the report to the Title IX Coordinator and proper Deputy.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

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Specific location:

Involved Parties

Please list all individuals involved. For non-students, please list a Social Security Number or Drivers License number in the block labeled ID Number, if available.

Name or Organization

Select Gender

Select UP Role

ID Number (Optional)

DOB (YYYY-MM-DD) (Optional)

Phone number

Email address

Hall/Address

Incident Information

Be sure to provide as much information as possible about the alleged incident.

Are you reporting this incident for yourself or for another person?(Required)

I experienced this situation Someone I know experienced this situation

This field is required.

Please provide a narrative of the alleged incident. Be sure to provide as much information as you have about the alleged incident.(Required) This field is required.

Please indicate other resources that have been notified:

Rape Crisis/Anti-Violence Support Center University of Portland Campus Safety Portland Police Department (or any other Law Enforcement Agency) University Health and Counseling Center ProtoCall Confidential Program Coordinator Other

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Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. Maximum 12 megabytes per file. Attachments require time to upload, so please be patient after you click to submit this report. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Incident Information

Supporting Documentation

Submission