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Title IX Discrimination/Harassment Concern Reporting Form


Before you begin:

1. If this is an emergency that involves an imminent risk of harm to self or others

  • Contact Public Safety at 516-877-3511, or Dial '5' from any campus phone;
  • Call the Garden City Police Department at (516) 465-4100, or;
  • Call 911

2. Take this action prior to filling out this referral form. Referrals are reviewed during normal business hours and may not be monitored after hours, on weekends, or
          during official University holidays. This form is NOT designed to report emergencies.

3. You should authenticate your credentials by  to access this form.

4. If you have questions about if this form is appropriate to use to report your concerns, please contact the Office of Community Concerns and Resolution at
 516-877-6864 or by email at occr@adelphi.edu

5. To speak with the Title IX office directly, please contact TitleIX@adelphi.edu, visit Levermore Hall room 207, or reach us by phone at 516-877-4819.

6. This form allows a member of the Adelphi Community, including all vendors and visitors, a way to report specific information related to the following:

  • an allegation of sex-based discrimination
  • an allegation of sex-based harassment including sexual assault, dating violence, domestic violence, stalking, and/or sexual harassment
  • retaliation

For more information on what is covered under this umbrella, please visit the Sex Discrimination, Sexual Misconduct and Other Prohibited Conduct Grievance Procedures.

Background Information

This form is designed to provide Â鶹ֱ²¥ students, staff, faculty, vendors, or visitors with an easy method to report specific information related to an alleged incident(s) of Title IX sex-based discrimination, including sexual assault, dating and domestic violence, stalking and sexual harassment.You are not required to complete the entire form in order for the allegation to be submitted. The University will use the information provided to begin an investigation, which may include contacting the complainant, respondent, and/or any potential witnesses. However, if the report does not contain specific information, the University’s investigation and response may be limited.

 
Email address must be of a valid format.
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Select the category of the respondent (accused)
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Involved Parties

Please list all of the involved parties in this incident, including yourself.

Involved party 1

Questions

Please complete the following questions to assist in the processing of your report.

If you are filing a report of sex-based discrimination , please indicate the protected status(es) that are part of the alleged behavior. For other discrimination/harassment based on a protected status, please consult either the Code of Conduct (for reports accusing students) or the Prohibited Discrimination and Harassment Policy (for reports accusing employees and visitors):
You must make at least one selection.
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What remedy are you seeking? Please note that your requested remedy may not be granted, due to law or other university policies.(Required)
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Please acknowledge the statement below: By submitting this form, the information I have provided is true and accurate to the best of my knowledge.(Required)
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Supporting Documentation

Please use this section to upload any supporting information. (any file type is accepted) 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission