JALC.EDU

Title IX Incident Reporting Form

Home » Title IX Incident Reporting Form

Background Information

John A. Logan College strongly encourages all good-faith reports, and will respond to all reports based on the nature and quality of the information that is shared. JALC wishes to support you and others affected by the contents of this report. The college understands, however, that there may be reasons why you might choose to withhold your identity or other portions of the narrative now, or indefinitely. Anonymity: You may wish to identify yourself through the fields in this section, or you may elect to remain anonymous. You may choose to identify yourself in the future or not. Be advised that any information included in this report may be shared with the person(s) whose behavior is being reported. If you are uncertain about whether you should include particular names or information about others (e.g. witnesses), please contact the Assistant Provost of Student Affairs at 618-985-2828, Ext. 8386.

If you would like for your report to be confidential you can choose that option from the dropdown menu below.

If you are wanting to submit a report to Campus Police, please use the Safety Review Request Form.

Formal Discrimination and Harassment (Title IX) Incident Reporting Form

Please indicate which applies to you *

Name

First

Last

Phone

Confirm Email

Your physical address

Urgency of this report *

Date of Incident *

Time of Incident

Location of Incident *

Specific Location

Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide.

Person Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone

Address

ADD INFORMATION FOR A SECOND INVOLVED PARTY.

Person Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone

Address

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how). *

Describe the specific harm you have suffered resulting from the incident(s). *

Describe the outcome (s) you expect from filing your complaint. Be as specific as possible. *

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5MB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

File Upload

Click or drag a file to this area to upload.