Campus Incident Report

Please use this form if you are a Perry Technical Institute student, faculty or staff member or visitor wishing to communicate information about an incident of sexual harassment or assault in violation of the Anti-Harassment Policy, the Drug and Alcohol Policy, or the Weapons and Violence Policy to the school on your own behalf or on behalf of another person.

First Name Last Name I am a Email Phone Best Time to Contact Please provide a detailed description of the incident Where did this incident take place? Date of incident Time of incident

Other

Involved Parties

Please list the names of all faculty, staff, students or other people involved, or who may have witnessed the incident.

Name or Program Gender Role Contact Information

Do you have an immediate concern for your safety? If Yes or Unsure, please describe your concern. How would you prefer to receive follow-up contact from the school?

Supporting Documentation (optional)

If you have photos, video, email and other supporting documentation, please upload here or email to titleix@perrytech.edu. File upload is limited to 30MB. Please submit larger files and video via email.

Attachment 1 Attachment 2 Attachment 3 Attachment 4 Attachment 5 Attachment 6

Information

Topics

Resources

Campus Incident Report

Involved Parties

Supporting Documentation (optional)

Information

Topics

Resources

Information

Topics

Resources

Connect

Campus Incident Report

Involved Parties

Supporting Documentation (optional)

Information

Topics

Resources

Connect