Title IX/ Sexual Harassment Reporting Form

If you need to report an emergency or are reporting an incident that poses an imminent risk of harm, call Campus Security at (901) 572-2911, or dial 911. Please know that completing this form does not substitute filing a report with the police.

This form should be used to report concerns pertaining to possible violations of the Baptist Health Sciences University (BHSU) Sexual Harassment policy, including gender based discrimination, dating violence, domestic violence, hostile environment, sexual assault, nonconsensual sexual contact, sexual exploitation, sexual harassment, stalking, retaliation, or other forms of sexual misconduct. Upon receipt of the report, BHSU will review the matter and take proper steps to investigate, stop, prevent, and remedy prohibited conduct in accordance with University policies.

BHSU respects the sensitivity of the information that may be included in this form and will make reasonable efforts to protect the privacy of those involved, in accordance with applicable state and federal law, while balancing the need to gather information to address the incident and take steps to eliminate prohibited conduct in order to protect the campus community.

Baptist University protects against retaliation of any kind against persons reporting harassment or any person's participation in the complaint or investigation process.

If you would like to speak with someone about completing this form, please call the Title IX Coordinator, James Knox at (901) 572-2510.

You can find more information about BHSU policies and procedures regarding sexual harassment at Baptist Sexual Harassment Policy and Procedures Policy

Background Information

The personally identifying information you provide below will be kept confidential.
Please complete all fields.

Your full name:

Your position/title:

Your phone number:

Email Address

Type of Complaint (Required):

Urgency of this report (Required):

Date and time of incident (Required):

Location of incident (Required):

Involved Parties

Please identify the person(s) who are involved in the incident. Please list as many involved parties as you know and include as much information as you can as this information is tremendously helpful during the investigation.

Name or Organization:

Gender:

Role:

About the Incident

In order for Baptist Health Sciences University to effectively investigate the incident, we need to know as much about what happened as possible.

The information you provide will be kept private and shared only with necessary and essential personnel. During the course of the investigation process, this information may be shared with the alleged perpetrator. However, this will not occur without first consulting with the victim as to their preferred approach to handling the situation.

Please provide a detailed description of the incident/concern using specific concise, objective language (who, what, when, where, why, and how).(Required)

Was law enforcement involved with the incident?

Yes

Unknown

If law enforcement was involved, please select the agency that responded.

Memphis Police Department

Shelby County Sheriff

Other law enforcement agency

Did anyone sustain an injury or experience a medical condition during the incident?

Yes

Unknown

Was anyone transported to a hospital?

Yes, via ambulance

Yes, via police

Yes, via personal vehicle

Unknown

Do you have any immediate concerns of safety or health? If yes, please explain.

If you are the victim of misconduct, please describe how you would prefer the University to respond to the situation. (You will not be held to this response; it just gives us a starting point.)

Background Information

Involved Parties

About the Incident

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