Sexual Harassment and Discrimination Incident Report

Do not use this form to report events presenting an immediate threat to life or property. If you require emergency assistance, please contact Campus Safety and Security at (304) 829-7744.

Why use this form?

This form is available for reporting incidents of harassment, including, but not limited to sexual violence and discrimination that you believe may be in violation of the Bethany College Title IX/Sex Discrimination Policy. If you have witnessed a possible violation of the policy or had such a violation reported to you, you can use this form to notify the College. Reports can also be made directly to the Title IX Coordinator by phone at (304) 827- 7631 or by email at titleIX@bethanywv.edu.

Who should use this form?

This form can be used by students, faculty, staff and visitors wishing to file a report on behalf of another person. Employees should use this form to satisfy their mandatory reporting obligation.

I what to make a complaint on my own behalf, and this does not seem to be the right form. What should I do?

If you want to bring a complaint on your own behalf (i.e., if you believe that you have been the victim of harassment or some other form of discrimination), please use the Bethany College Sexual Harassment and Discrimination Complaint Form.

If I am an employee, does completing this form satisfy my mandatory reporting obligation?

Yes. All employees – except those with legal privilege, such as Renee Stock, College Counselor, staff at the Wellness Center, and Rev. Scott Thayer, College Chaplain – are subject to the mandatory reporting obligation and must report allegations of what they believe may be violations of the Bethany College Title IX/Sex Discrimination Policy to the Deputy Title IX Coordinator. Completing this form satisfies that obligation. The Title IX Coordinator will contact you if more information is needed.

What happens after I fill out this form?

The information is sent to the Title IX Coordinator, who will determine what, if any, action by the College is necessary. You will receive a follow-up message from the Title IX Coordinator within three business days.

Is the information on this form confidential?

The College will make every effort to protect the privacy of all involved, but the information you provide in completing this form is not confidential and may be shared as necessary for the College to take appropriate action.

Incident Report Form

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I wish to report possible discrimination/harassment in violation of Bethany College's Nondiscrimination and Anti-harassment Police based upon:

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Please describe the incident(s) at issue. Be as specific about what happened as possible, including information about the people involved. If the complainant/victim has not consented to having his/her name revealed, do not use any real names or provide any other identifying information in your description. Instead use language like the following: "Jane Doe reported to me that on June 5, 2013, John Doe..." Otherwise, feel free to use real names.

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If he or she consented to having his or her name revealed, provide the following contact information, if known, about the complainant/victim: Full name; phone with area code; email address: