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Center for Human Rights
Incident Report Form
For Departmental Reports Only
All employees and students of Washington State “Unwelcome sexual advances, requests for
University, as well as other individuals, are sexual favors, and other verbal or physical
encouraged to report complaints to the conduct of a sexual nature when:
appropriate department Chair, Dean, or
Administrative Supervisor first to allow for a 1. Submission to such conduct is made
resolution at the departmental or unit level. If either explicitly or implicitly a term or
condition of an individual’s employment
the complaining person is not satisfied with the
or education,
resolution at this level, such person may file a
2. Submission to or rejection of such
complaint with the Center for Human Rights
conduct by an individual is used as the
(CHR). basis for employment or educational
A Department Representative should decisions affecting such individual, or
complete this form to:
3. Such conduct has the purpose or effect of
make an inquiry or seek clarification;
notify the CHR of an incident; unreasonably interfering with an
obtain advice; individual’s work or educational
seek assistance; performance or creating an intimidating,
request an investigation, or hostile or offensive environment.”
report a resolved incident.
Please complete this form for each incident
Administrative Responsibility
reported and forward it to the CHR. Deans, Directors, Superintendents,
Supervisors, Department Chairs, and
Unlawful Discrimination Cooperative Extension EEO Representatives
should:
Discrimination on the basis of race, sex, Listen to concerns of policy violations.
religion, color, creed, national or ethnic origin; Intervene to prevent retaliation.
physical, mental or sensory disability; marital Resolve the complaint at the lowest
status, sexual orientation, and status as a level, if possible, before forwarding to the
Vietnam-era or disabled veteran is prohibited by CHR or the Ombudsman’s Office.
WSU policy. Decisions affecting an individual Seek advice and assistance from the
cannot be made on the basis of one of these CHR or the Ombudsman’s Office.
factors. If unable to resolve, refer the person
WSU’s discrimination policy explicitly making the allegation and/or the accused to
prohibits sexual harassment as a form of the CHR for further advice or information,
unlawful sex discrimination. Sexual harassment assistance, or investigation.
is defined as: Notify the CHR by phone or in writing
immediately upon receipt of any
complaint.
Incident Report Form
I. (Person Completing form)
Name: Date Completed:
Position: Status:
Department: Campus Zip:
Date and Location of Incident:
II. REASON FOR USE OF THIS FORM
Inquiry or Clarification Notification of Incident Other: ______________________
Advice Assistance
Investigation Resolved incident
III. PERSON WHO REPORTED PROBLEM OR MADE A COMPLAINT
Name: Department:
Home Address: Campus Zip:
Work Phone No.:
Email: Home Phone No.:
Status: Student Faculty Adm/Prof Classified Staff Other
For Statistical reporting purposes, please check each category that applies:
Race/Ethnicity/Color Religion Gender Sexual Orientation
African American Catholic Male Heterosexual
Afro-Hispanic/Latino Jewish Female Bisexual
Hispanic/Latino Muslim Transgender Gay
Asian/Pacific Islander Protestant Other: Lesbian
Native American Hindu Other:
Alaska/Hawaii Native Atheist
White/Caucasian Other:
Other:
National Origin Age Veteran Disability
United States 18-29 Disabled Vet Yes
Other: 30-39 Vietnam Era Vet No
40-64
65 and over
V. GENERAL BASIS FOR COMPLAINT
Race or Ethnicity Disability Sexual Orientation
Color Vietnam Era Veteran Age
National Origin Disabled Veteran Retaliation
Religion or Creed Sex or Gender Pregnancy
Marital Status Sexual Harassment Other:
VI. SPECIFIC TYPE OF ACTION OR BEHAVIOR
Verbal Abuse or Harassment Unequal Work Assignments Co-worker problem
Physical Abuse or Harassment Reclassification Termination
Promotion/Tenure Layoff Hiring Process
Pay Equity Classroom Environment Compensation
Performance Appraisal Advisor/Professor Problem Working Conditions
Supervisor/Manager Problem Other:
IV. PERSON ALLEGED TO HAVE COMMITTED AN ACT OF DISCRIMINATION/HARASSMENT
Name: Position:
Department: Campus Zip:
Status: Student Faculty Adm/Prof Classified Staff Other
DETAILED STATEMENT OF INCIDENT (Attach additional sheet if necessary)
STATEMENT OF ACTION TAKEN, IF ANY (Attach additional sheet if necessary)
Signature of Person Reporting Signature of Hiring Authority
ROUTING INSTRUCTIONS
Forward this form to CHR as soon as the form is completed and signed. Reports of sexual harassment
must be reported to the Center immediately after receipt of the complaint by phone or in writing.
CHR Contact:
Raúl M. Sánchez, Director
Center for Human Rights
French Administration 225
Campus Zip 1022
Phone: (509) 335-8288
Fax: (509) 335-5483
ADDITIONAL SOURCES AVAILABLE FOR COMPLAINT RESOLUTION INCLUDE:
University Ombudsman Human Resource Services
Wilson Hall 2 French Administration 139
335-1195 (zip 4002) 335-4521 (zip 1014)
Department of Residence Life Office of Student Conduct
Streit-Perham Hall Lighty Student Services Bldg 360
Art McCarten Suite 335-4532 (zip 1066)
335-1227 (zip 1724)
To be completed by the Center for Human Rights:
Date Received: Case number:
Date Closed: Investigator:
Disposition:
A. Violation of WSU Policy
B. No Violation
C. No Violation, with recommendations
D. Withdrawn
F. No Investigation warranted
Comments:
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