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<!DOCTYPE html> <html class="no-js" lang="en"> <head> <title>Discrimination and Sexual Misconduct Report Form</title> <meta charset="utf-8"/> <meta content="ie=edge" http-equiv="x-ua-compatible"/> <meta content="width=device-width, initial-scale=1, shrink-to-fit=no" name="viewport"/> <script src="/js/jquery-latest.js" type="text/javascript"></script> <script src="/js/modernizr.js" type="text/javascript"></script> <script src="/js/refresh/global.js?v=20160726" type="text/javascript"></script> <link href="/css/refresh/global.css?v=20160726" rel="stylesheet"/> <link href="/eos-forms/css/main.css?c=1" rel="stylesheet"/> <script src="/cdn/jsFormValidator/js/jsFormValidator.min.js" type="text/javascript"></script> <script src="/eos-forms/js/main.js?c=2" type="text/javascript"></script> <style> /* fixes a margin issue caused by site-name appearing outside the header */ .uh-header-app:not(.uh-header-primary) .site-name { margin-top: 0;} /* removes the redundant menu-button appearing inside the 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<li><a href="/">UH Home</a><span class="divider">/</span></li> <li><a href="/equal-opportunity/">Equal Opportunity Services</a></li> <li class="active">Discrimination and Sexual Misconduct Report From</li> </ul> <section class="row"> <div class="nav-secondary col-sm-12 col-md-4"> <h2 class="site-title"> <a title="Equal Opportunity Services" shape="rect" href="/equal-opportunity/">Equal Opportunity Services</a> </h2> <nav role="navigation"> <ul> <li class=""> <a title="Title IX/Sexual Misconduct Resources" href="/equal-opportunity/titleIX-sexual-misconduct/getting-help/">Title IX/Sexual Misconduct Resources</a> </li> <li class=""> <a title="Anti-Discrimination Resources" href="/equal-opportunity/tools-and-resources/">Anti-Discrimination Resources</a> </li> <li> <a href="/equal-opportunity/about-eos/contact-us/" title="Contact Us">Contact Us</a> </li> <li> <a href="https://uhsystem.edu/compliance-ethics/_docs/sam/01/1d8.pdf" title="Sexual Misconduct Policy" target="policy">Sexual 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for="first_name" class="control-label col-md-4">* First Name</label> <div class="col-md-8"> <input type="text" name="first_name" id="first_name" class="form-control" autofocus required data-error-message="First Name is required" /> </div> </div> <div class="form-group"> <label for="last_name" class="control-label col-md-4">* Last Name</label> <div class="col-md-8"> <input type="text" name="last_name" id="last_name" class="form-control" required data-error-message="Last Name is required" /> </div> </div> <div class="form-group" class="control-label col-md-4"> <label for="title" class="control-label col-md-4">Title</label> <div class="col-md-8"> <input type="text" name="title" id="title" class="form-control" /> </div> </div> <div class="form-group" class="control-label col-md-4"> <label for="department" class="control-label col-md-4">Department</label> <div class="col-md-8"> <input type="text" name="department" id="department" class="form-control" /> </div> </div> <div class="form-group"> <label for="status" class="control-label col-md-4">* Status</label> <div class="col-md-8"> <select class="form-control" id="status" name="status" data-error-message="Status is required" required> <option value="">Please Choose...</option> <option value="Student">Student</option> <option value="Staff">Staff</option> <option value="Faculty">Faculty</option> <option value="Visitor">Visitor to Campus</option> <option value="Unaffilliated">Unaffiliated</option> </select> </div> </div> <div class="form-group"> <label for="phone1" class="control-label col-md-4">* Phone Number</label> <div class="col-md-8"> <input type="text" name="phone" id="phone1" class="form-control" required data-rule="phone" /> </div> </div> <div class="form-group"> <label for="email1" class="control-label col-md-4">* Email</label> <div class="col-md-8"> <input type="email" name="email" id="email1" class="form-control" required data-rule="email" /> </div> </div> <div class="form-group"> <label for="nature" class="control-label col-md-4">* Nature of this Report</label> <div class="col-md-8"> <input type="checkbox" value="Discrimination" name="nature_category[]" id="discrimination" />  Discrimination<br /> <input type="checkbox" value="Sexual Misconduct" name="nature_category[]" id="sexual-misconduct" />  Sexual Misconduct <select multiple class="form-control" name="nature[]" id="nature" data-error-message="Nature of this Report is required" required> <option class="discrimination" value="Race/Origin">Race/Origin</option> <option class="discrimination" value="Color">Color</option> <option class="discrimination" value="Sex">Sex</option> <option class="discrimination" value="Age">Age</option> <option class="discrimination" value="Religion">Religion</option> <option class="discrimination" value="Disability">Disability</option> <option class="discrimination" value="Veteran Status">Veteran Status</option> <option class="discrimination" value="Genetic Information">Genetic Information</option> <option class="discrimination" value="Gender Expression">Gender Expression</option> <option class="discrimination" value="Gender Identity">Gender Identity</option> <option class="discrimination" value="Sexual Orientation">Sexual Orientation</option> <option class="sexual-misconduct" value="Sexual Harassment">Sexual Harassment</option> <option class="sexual-misconduct" value="Non-Consensual Sexual Contact">Non-Consensual Sexual Contact</option> <option class="sexual-misconduct" value="Sexual Assault">Sexual Assault</option> <option class="sexual-misconduct" value="Sexual Exploitation">Sexual Exploitation</option> <option class="sexual-misconduct" value="Sexual Intimidation">Sexual Intimidation</option> <option class="sexual-misconduct" value="Dating Violence">Dating Violence</option> <option class="sexual-misconduct" value="Domestic Violence">Domestic Violence</option> <option class="sexual-misconduct" value="Stalking">Stalking</option> <option class="discrimination sexual-misconduct" value="Retaliation">Retaliation</option> <option class="sexual-misconduct" value="Failure to Report">Failure to Report</option> </select> </div> </div> <div class="form-group"> <label for="incident_date" class="control-label col-md-4">Incident Date</label> <div class="col-md-8"> <input type="text" name="incident_date" id="incident_date" class="form-control datepicker" data-rule="date_mm_dd_yyyy" /> <input type="checkbox" name="date_not_known" id="date_not_known" /> Unknown </div> </div> <div class="form-group"> <label for="incident_location" class="control-label col-md-4">Incident Location</label> <div class="col-md-8"> <select class="form-control" name="incident_location" id="incident_location"> <option value="">Please Choose...</option> <option value="On Campus">On Campus</option> <option value="Off Campus">Off Campus</option> <option value="Unknown">Unknown</option> </select> </div> </div> <div class="form-group" id="spec-loc"> <label for="specific_location" class="control-label col-md-4">Specific Location</label> <div class="col-md-8"> <input type="text" name="specific_location" id="specific_location" class="form-control" /> </div> </div> <div class="form-group button-area"> <button class="btn btn-primary pull-right" onclick="save_step()">Next</button> </div> </div> <div id="step2" class="step form-horizontal"> <h2>Step 2: Involved Parties</h2> <input type="hidden" value="2" name="step" /> <fieldset> <legend>Possible Victim Information (person who may have experienced negative treatment).</legend> <div class="form-group"> <label for="name" class="control-label col-md-4">Possible Victim name</label> <div class="col-md-8"> <input type="text" name="name" id="name" class="form-control" /> </div> </div> <div class="form-group"> <label for="psid" class="control-label col-md-4">PSID</label> <div class="col-md-8"> <input type="text" id="psid" name="psid" class="form-control" data-rule="emplid" /> </div> </div> <div class="form-group"> <label for="gender" class="control-label col-md-4">Preferred Pronouns</label> <div class="col-md-8"> <input type="text" name="gender" id="gender" class="form-control" /> </div> </div> <div class="form-group"> <label for="role" class="control-label col-md-4">Status</label> <div class="col-md-8"> <select class="form-control" id="role" name="role"> <option value="">Please Choose...</option> <option value="Student">Student</option> <option value="Staff">Staff</option> <option value="Faculty">Faculty</option> <option value="Visitor">Visitor to Campus</option> <option value="Unaffilliated">Unaffiliated</option> </select> </div> </div> <div class="form-group"> <label for="phone" class="control-label col-md-4">Phone</label> <div class="col-md-8"> <input type="text" name="phone" id="phone" class="form-control" date-rule="phone" /> </div> </div> <div class="form-group"> <label for="email" class="control-label col-md-4">Email</label> <div class="col-md-8"> <input type="email" name="email" id="email" class="form-control" data-rule="email" /> </div> </div> </fieldset> <fieldset> <legend>Alleged Person's Responsible (accused person or person possibly responsible for negative treatment)</legend> <div class="form-group"> <label for="responding_name" class="control-label col-md-4">Alleged Person's Name</label> <div class="col-md-8"> <input type="text" name="responding_name" id="responding_name" class="form-control" /> </div> </div> <div class="form-group"> <label for="responding_psid" class="control-label col-md-4">PSID</label> <div class="col-md-8"> <input type="text" id="responding_psid" name="responding_psid" class="form-control" data-rule="emplid" /> </div> </div> <div class="form-group"> <label for="responding_gender" class="control-label col-md-4">Preferred Pronouns</label> <div class="col-md-8"> <input type="text" name="responding_gender" id="responding_gender" class="form-control" /> </div> </div> <div class="form-group"> <label for="responding_role" class="control-label col-md-4">Status</label> <div class="col-md-8"> <select class="form-control" id="responding_role" name="responding_role"> <option value="">Please Choose...</option> <option value="Student">Student</option> <option value="Staff">Staff</option> <option value="Faculty">Faculty</option> <option value="Visitor">Visitor to Campus</option> <option value="Unaffilliated">Unaffiliated</option> </select> </div> </div> <div class="form-group"> <label for="responding_phone" class="control-label col-md-4">Phone</label> <div class="col-md-8"> <input type="text" name="responding_phone" id="responding_phone" class="form-control" date-rule="phone" /> </div> </div> <div class="form-group"> <label for="responding_email" class="control-label col-md-4">Email</label> <div class="col-md-8"> <input type="email" name="responding_email" id="responding_email" class="form-control" data-rule="email" /> </div> </div> </fieldset> <p>If there is more than one possible victim or alleged person responsible, you can describe their information in your comments later in this form.</p> <div class="form-group button-area"> <button class="btn btn-default pull-left" onclick="previous_step();return false;">Previous</button> <button class="btn btn-primary pull-right" onclick="save_step(); return false;">Next</button> </div> </div> <div id="step3" class="step"> <h2>Step 3: Additional Questions</h2> <input type="hidden" value="3" name="step" /> <div class="form-group"> <label for="who" class="control-label">* Does either party know you are making this report?</label> <div> <select class="form-control" id="who" name="who" data-error-message="We are required to collect this information" required> <option value="">Please Choose...</option> <option value="Yes, I was directly impacted by this incident.">Yes, I was directly impacted by this incident.</option> <option value="Yes, at least one party is aware that I am making this report.">Yes, at least one party is aware that I am making this report.</option> <option value="No, neither party is aware that I am making this report.">No, neither party is aware that I am making this report.</option> </select> <div class="info">We are required to collect this information.</div> </div> </div> <div class="form-group"> <label for="aware_incident_date" class="control-label">* When did you become aware of this incident?</label> <div> <input type="text" name="aware_incident_date" id="aware_incident_date" class="form-control datepicker" required data-error-message="This field is required" /> </div> </div> <div class="form-group"> <label for="responsible_employee" class="control-label">* Are you reporting as a Responsible Employee?</label> <div> <input type="radio" id="re-1" value="1" name="responsible_employee" required />  <label for="re-1"> <strong>Yes</strong></label>   <input id="re-2" type="radio" value="0" name="responsible_employee" />  <label for="re-2"><strong>No</strong></label>   <input id="re-3" type="radio" value="-1" name="responsible_employee" />  <label for="re-3"><strong>Unsure</strong></label> </div> </div> <div class="form-horizontal"> <div class="form-group button-area" id="re-toggle"> <h4>If yes,</h4> <div> <label class="control-label col-md-6">* What is your PeopleSoft ID?</label> <div class="col-md-6"><input type="text" id="responsible_psid" name="responsible_psid" class="form-control" data-rule="emplid" /></div> <label class="control-label col-md-6">* What is your Department Name?</label> <div class="col-md-6"><input type="text" id="deptname" name="deptname" class="form-control" data-error-message="Department Name is required" /></div> </div> </div> </div> <div class="form-group"> <label for="incident" class="control-label"><strong>* Description of Incident:</strong> Provide as much detail as you can regarding the date(s) and place(s) of the incident(s); a detailed description of the specific conduct that is the basis of the concerns; and any witnesses (name and contact information), if applicable.</label> <textarea name="incident" id="incident" class="form-control" data-min-length=4 data-error-message="Description of the incident is required" required></textarea> </div> <div class="form-group"> <label for="other" class="control-label"><strong>Other Information:</strong> Please provide any other information you believe might be helpful. For example, text messages or other evidence, whether you filed a criminal complaint, and any other extenuating circumstances. You may attach related documents or images in the supporting documentation section below.</label> <textarea name="other" id="other" class="form-control" ></textarea> </div> <div style="clear: both;"> </div> <fieldset> <legend><strong>* Action Requested:</strong>By completing and submitting this form I am requesting the following:</legend> <div class="form-group"> <div class="col-md-1"> <input id="action-1" required type="radio" value="I am initiating a Report of an alleged university policy concern and would like to be contacted with more information regarding my rights and responsibilities outlined in the UHS Anti-Discrimination and/or Sexual Misconduct Policies." name="action" /> </div> <div class="col-md-11"> <label for="action-1">I am initiating a <strong>Report</strong> of an alleged university policy concern and <strong>would like to be contacted</strong> with more information regarding my rights and responsibilities outlined in the UHS Anti-Discrimination and/or Sexual Misconduct Policies.</label> </div> </div> <div class="form-group"> <div class="col-md-1"> <input id="action-4" required type="radio" value="I am submitting this report ANONYMOUSLY and DO NOT want to be contacted further about this matter." name="action" /> </div> <div class="col-md-11"> <label for="action-4">I am submitting this report <strong>ANONYMOUSLY and DO NOT want</strong> to be contacted further about this matter.</label> </div> </div> <div class="form-group"> <div class="col-md-1"> <input id="action-5" required type="radio" value="I am still undecided regarding any action to request." name="action" /> </div> <div class="col-md-11"> <label for="action-5">I am still undecided regarding any action to request.</label> </div> </div> </fieldset> <hr /> <div class="form-group"> <label for="criminal_report_file">* Have you filed a criminal report with the campus police?</label> <div> <div> <input type="radio" id="cfr-1" value="1" name="criminal_report" required />  <label for="cfr-1"><strong>Yes</strong></label>   </div> <div> <input type="radio" id="cfr-2" value="0" name="criminal_report" />  <label for="cfr-2"><strong>No</strong></label> <div class="info">Please note that if you would like to contact University of Houston Police Department, they have a 24/7 phone number <a href="tel:+17137433333" title="call UHPD">713-743-3333</a> and more information online at <a href="https://uh.edu/police" title='UHPD website' target="_blank">uh.edu/police</a>.</div> </div> </div> </div> <div class="form-group"> <label> <input type="checkbox" name="assistance" id="assistance" value="1" />  Are you in need of living, class, or work assistance related to this report? If so, please explain. </label> <textarea class="form-control" name="assistance_explain" id="assistance-explain" data-error-message="Please explain the type of assistance needed"></textarea> </div> <div class="form-horizontal"> <div class="form-group button-area"> <button class="btn btn-default pull-left" onclick="previous_step();return false;">Previous</button> <button class="btn btn-primary pull-right" onclick="save_step(); return false;">Next</button> </div> </div> </div> <div id="step4" class="step form-horizontal"> <h2>Step 4: Supporting Documentation/Attachments </h2> <input type="hidden" value="4" name="step" /> <p>Photos, video, email and other supporting documents may by attached below. Each file cannot be larger than 15 MB.</p> <span class="btn btn-success fileinput-button"> <i class="glyphicon glyphicon-plus"></i> <span>Select files...</span>  <input id="fileupload" type="file" name="files[]" multiple> </span> <br> <br>  <div id="progress" class="progress"> <div class="progress-bar progress-bar-success"></div> </div>  <div id="files" class="files"></div> <br class="clearfix" /> <div class="form-group button-area"> <button class="btn btn-default pull-left" onclick="previous_step();return false;">Previous</button> <button class="btn btn-primary pull-right" onclick="next_step(); return false;">Next</button> </div> </div> <div id="step5" class="step form-horizontal" data-final="review"> <h2>Step 5: Final Review </h2> <div class="info"><strong>**This page is a preview and form is not complete yet. You must select “Submit” below to send this information to UH Equal Opportunity Services.**</strong></div> <div id="final-review"></div> <input type="hidden" value="5" name="step" /> <div class="form-group button-area"> <button class="btn btn-default pull-left" onclick="previous_step();return false;">Previous</button> <button class="btn btn-primary pull-right" onclick="closingSequence();">Submit Report</button> </div> </div> <script> function closingSequence(){ save_to_db(()=>{ window.onbeforeunload=null; clearStorage(); window.location.href='process/submit.php'; }); } </script> </div> </article> </section> </div> </main> <footer class="uh-footer"> <nav aria-label="Global Footer" class="global-footer"> <div class="container"> <p class="copyright">©2025 University of Houston. 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