Chatham University Title IXIncident Reporting Form The Title IX office monitors received Incident Reports during normal University business hours (9AM - 5PM, M-F). For urgent, emergency cases (e.g., sexual assault), please call the 24-hour emergency Chatham Public Safety hotline at 412-365-1111 or 911. For all other reports, someone from the Title IX office will be in touch with the person submitting the Incident Reporting Form to follow up. *Denotes a required field. All others are optional. Background Information Name *Affiliation with Chatham University : Student Faculty Staff Police Other Phone Email Physical Address *Type of Prohibited Conduct : Sexual or gender-based harassment Sexual Assault Relationships or Interpersonal Violence Stalking Other If Other : *Date of Incident : Time of Incident : *Location of Incident : Off Campus Online Chatham Apartments - Tower A Chatham Apartments - Tower B Chatham Apartments - Tower C Chatham Apartments - Tower D Chung Apartments Fickes Hall Linzer Apartments Haber Apartments Hicks Estate Laughlin House Maryland Duplex Orchard Hall (Eden Hall Campus) Pelletreau Apartments Rea House Woodland Hall Shadyside Campus Eden Hall Campus East Side Campus If off campus, please enter location : Specific location : *Were you involved in the incident you're reporting? : Yes No Involved Parties Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide. For non-students, please list an SSN or Drivers License number in the block labeled SID (Student ID #) if available. Name : Select Gender : Male Female Transgender Other Select Role : Non-Student Student Respondent Person of Concern Witness ID Number Date of Birth Phone Email On or Off Campus : On Campus Off Campus Hall/Address Add involved party Remove Details/Descriptive Information Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how). Officials (University staff, faculty, public safety, Campus Public Safety, RA) contacted or present? [Please list their name(s) and title(s)] If a police report was filed, please provide the name of the police department the report was filed with (if known). Chatham Police City of Pittsburgh Police Other If other police department, please enter jurisdiction : Have you or the victim sought medical attention? Yes No Anything else you'd like us to know?