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Sexual Misconduct/Discrimination Referral & Report Form


Please note submissions to this form may not be reviewed outside of normal business hours. If this is an emergency, please contact the Cal Poly Humboldt University Police Department at 9-1-1.

 

  • This report does not automatically initiate a Title IX Investigation. It provides you with an opportunity to inform the Title IX & DHR Prevention Office of your experience and to receive supportive measures and information about your options.
  • This report is received and reviewed by staff from the Title IX & DHR Prevention Office. More information on confidentiality and what happens after you report can be found on our website.
  • To access confidential support options, advocacy, and referral services, reporting parties may contact any of the following services:
    • Campus Advocate Team - (707) 445-2881, 24/7
    • Counseling and Psychological Services (CAPS) - (707) 826-3626, 24/7
    • Additional Options
  • If you choose to file a formal complaint, the information provided on this report may be used to form the initial basis of your complaint.
  • This report may be completed anonymously. We may be limited in our response if a report is anonymous.
  • While there is no statute of limitations on sexual misconduct reports, prompt reporting will better enable the University to provide appropriate remedies and/or take action.
Please visit our website for more information on the CSU Nondiscrimination Policy and procedures.

Background Information

While anonymous reports are accepted, you are STRONGLY encouraged to provide your name and contact information in order to allow us to most effectively address the concerning behavior.
 
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Involved Parties

Please answer the questions below to the best of your ability. You may leave something blank if you are unsure of what to choose. If you need assistance, you can contact the Campus Advocate Team at (707) 445-2881 or reach out to our office at (707) 826-5177.
  • Complainant: select this role for the person who experienced the harm
  • Respondent: select this role for the person who is alleged to have committed the harm
  • Person of Concern: select this role if you are unsure
  • Witness: select this role if someone saw the harm or situation(s) occur
Involved party 1

Questions

Please answer the questions below to the best of your ability. If you need assistance, you can contact the Campus Advocate Team at (707) 445-2881 or reach out to our office at (707) 826-5177.
Complainant's affiliation to Cal Poly Humboldt (The person(s) reportedly impacted by the behavior)(Required)
You must make at least one selection.
Respondent's affiliation to Cal Poly Humboldt (The person(s) the report is made against)(Required)
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What is the approximate duration of the behavior(s) that you are reporting?(Required)
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I understand that this form must NOT be used to report emergencies requiring immediate response.(Required)
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Supporting Documentation

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

Submission