Online Report Form

This form is designed to provide students, staff, faculty, applicants, visitors, or others with an on-line method to report specific information related to an alleged incident(s) of discrimination, harassment (including sexual misconduct), or retaliation.

Regardless of whether a report results in a full investigation and adjudication under PPM 3010, the college helps reported victims of prohibited conduct by providing support and assistance services. These support and assistance services are intended to help a reported victim continue to access the working and learning environment at Salina Tech. Support and assistance services are also available to respondents.

You may file a complaint with the Vice President of Student Services in person, by regular mail, or by email. Generally, the VP of Student Services will need all of the information below. You may (but are not required to) print this form and bring it to the office in person, mail the form to the VP of Student Services, or submit it by email. To discuss your complaint with a member of the Title IX team, you can schedule a meeting in person, via telephone, or email at the contact information provided once you submit the form online.

Confidentiality: Complaints are confidential and will not be disclosed to anyone who does not have a need to know. This requirement applies to complainants, respondents, witnesses, and any others involved with a complaint. If you believe criminal conduct has occurred, then you should make a criminal complaint to the police. The criminal justice system and this Policy are separate procedures; however, reports must be made under both procedures to ensure that both will go forward.

Reporter's Information

First Name *

Last Name *

Phone Number *

Street Address *

Address Line 2

City *

State *

Email Address *

Zip Code *

Best way to contact you: *

Date of Incident: * +

Time of incident:

Continuing Harm: *

Location of incident: *

Involved Parties

Please list all persons involved. This includes the respondent and any witnesses to the incident. Definition of Roles: Complainant: is the person affected by the prohibited conduct. Respondent(s): is the person whom the complaint is about or the person who is believed to have caused the prohibited conduct. Witness(es): is any person with direct or indirect knowledge of the allegation(s) of prohibited conduct made in a complaint or report.

Name:

Person's role as it relates to the alleged incident:

Date of Birth: +

Phone number:

Email address:

Name:

Person's role as it relates to the alleged incident:

Date of Birth: +

Phone number:

Email address:

Questions

The discrimination impacted the follow: (please select all that apply) *

SATC academic performance, academic opportunities, or learning environment

SATC employment

SATC housing (KSU-P Dorms/SJMS Dorms)

Participation in a SATC sponsored event or program

Other non-college related impact

None of the above

Please provide as much information as possible including but not limited to: the specifics of the conduct, the dates and locations of the conduct, and the impact the conduct has had on the complainant’s employment, learning or living environment, or the complainant’s ability to participate in university programs. Attach additional pages and relevant documents to provide as much information as possible. *

Have you brought this matter to the attention of any other department(s) at the College, other than the VP of Student Services? If so, please list the name(s) and departments of all other persons with whom you have discussed the matter.

Police File Number: (if applicable)

I certify the information provided is true and accurate to the best of my knowledge. *

Agree

Disagree

I understand that submitting this report constitutes official notice to Salina Tech and authorizes the institution to evaluate this concern pursuant to College Policy. *

I understand.

If you have safety concerns and would like us to contact you by a specified means or telephone number, please provide that information below.

Do you wish to request a reasonable accommodation of a disability in order to participate in the reporting and/or resolution process? *

Yes

No

If you are making a request for a reasonable accommodation of a disability, please state what accommodation(s) you are requesting.

What, if any, are your pronoun preferences? *

Supporting Documentation

Please attach any/all documentation you may have that is associated with this report. 1GB maximum total size. Attachments require time to upload, so please be patient after submitting this form.