Sexual Misconduct Reporting Form

Lake Region State College offers resources and support to all community members experiencing concerns of sexual misconduct, stalking, and dating and domestic violence. We encourage you to make us aware of these concerns so that we can offer support and resources to you and/or those involved. This form can be used by any member of the LRSC community (or non-community member) to report a concern of sexual misconduct, stalking, or dating or domestic violence in which the person responsible for the action is a Lake Region State College student or employee. If this is an emergency, please call 911.

PLEASE NOTE: While anonymous reports may be submitted and are reviewed by the Title IX Coordinator, the college's ability to address alleged misconduct reported by anonymous sources is significantly limited.

Reporter and Incident Information

Please use this section to provide us with your contact information and the date/location of the incident(s).

Your Full Name

Your Phone Number

Email Address

Your LRSC Connection *

Date of Incident *

Month

Day

Year

Time of Incident

Hour

Minute

Location of Incident *

Specific Location

Involved Parties

Please provide information for all people and/or organizations that are involved in this situation, including yourself.

Name or Organization

Gender

Role

Date of Birth

Month

Day

Year

Phone Number

Email Address

Other Parties Involved

Please provide information for all people and/or organizations that are involved in this situation, including yourself. (Leave blank if no other parties are involved)

Name or Organization

Gender

Role

Date of Birth

Month

Day

Year

Phone Number

Email Address

Other Parties Involved

Please provide information for all people and/or organizations that are involved in this situation, including yourself. (Leave blank if no other parties are involved)

Name or Organization

Gender

Role

Date of Birth

Month

Day

Year

Phone Number

Email Address

Description of the Concern

Please describe what has occurred

Providing additional information on why you are submitting this report will allow us to respond most appropriately (for example: I want the college to know. I am looking for resources or support. I am concerned for the student. I would like the person held accountable.)

File 1

Files must be less than 2 MB.
Allowed file types: jpg jpeg txt pdf doc docx xls xlsx.

File 2

Files must be less than 2 MB.
Allowed file types: jpg jpeg txt pdf doc docx xls xlsx.

File 3

Files must be less than 2 MB.
Allowed file types: jpg jpeg txt pdf doc docx xls xlsx.

Please email any documents, copies of social media, text messages, etc. to LRSC.KnowYour9@lrsc.edu.

Leave this field blank

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Reporter and Incident Information

Involved Parties

Other Parties Involved

Other Parties Involved

Description of the Concern