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This form allows faculty, staff, and students in the College of Education to report incidents so that they can be acted on and resolved in a timely manner. All information that is submitted is kept confidential. In the form below, please provide your contact information and the details of the incident. Provide as much information as you can to help us address your concern. All sections below are optional unless marked “Required.”

Any employee of MU (including student workers) submitting a mandatory report should complete all known fields. The information on this form will be reported to Civil Rights and Title IX. This form ensures that any incident is reported to the College of Education leadership. If you wish to be contacted to follow up on this concern, please include your contact information.

A copy of the report will be automatically emailed to you upon submission when you provide your email address.

Please provide your contact information and the details of the incident

Your full name:

Your position/title:

Your preferred phone number:

Your preferred email address:

The nature of this report (Required):

Date of incident (Required) MM/DD/YYYY

Location of incident (Required):

Specific location:

Involved Parties

Please provide:

the Complainant (person who is the alleged victim and/or experienced the harassment or discrimination being reported)
the Respondent (person(s), organization, or department accused of engaging in discrimination/harassment in violation of MU policy)
any known witnesses

Information about the involved parties (The next page of the form allows you to share information on other involved parties, if any)

Information about the involved parties (The next page of the form allows you to share information on other involved parties, if any)
	Name or Organization	Preferred Phone Number	Preferred Email Address	Any identifying information
Complainant	Complainant	Any known witness
	Name or Organization	Preferred Phone Number	Preferred Email Address	Any identifying information
Respondent	Complainant	Any known witness
	Name or Organization	Preferred Phone Number	Preferred Email Address	Any identifying information
Any known witness	Complainant	Any known witness

About the incident(s)

Please provide a detailed description of the incident(s) below. NOTE: You can describe more than one incident in this box; if doing so, please include dates, names, and locations, (if known) for each incident. (Required)

Supporting Documentation
Photos, video, email, and other supporting documents may be attached below. 100MB maximum total size.
Attachments require time to upload, so please be patient.

Additional Supporting Documentation
Photos, video, email, and other supporting documents may be attached below. 100MB maximum total size.

Concern addressal (You may select more than one option.)

I would like the MU Office of Civil Rights and Title IX to address this concern.
I would like the College of Education to address this concern directly.
I would like the College of Education to contact me to discuss how to address this concern.