Submit a Sex/Gender Discrimination, Harassment, Misconduct and/or Retaliation Report

For additional resources, or if you have questions, contact Avery Staley, Title IX Coordinator, at avery.staley@lr.edu or TitleIXCoordinator@lr.edu or 828.328.7443.

If you would like to make an anonymous complaint, you may complete this form with all details of the incident except your name and other identifying information. However, if you make an anonymous report, it will limit the university’s ability to respond. If you aren’t sure whether you want to report your name, we encourage you to talk through your options with a confidential resource, including a university counselor, pastor or student health provider.

Date of Report

Reporter Name

Phone Number

Is the Reporter

Does the complainant wish to remain confidential at this time?

(The complainant only wants their name and information about the incident to be shared with the Title IX Coordinator.)

Yes

Date and Time of Incident

Location of Incident

Please provide as much information about the incident as possible

Alleged individual against whom the grievance is asserted ("respondent")

Fist and Last Name

Gender

Phone Number

Does the respondent live on-campus or off-campus

On-campus

Off-campus

Was the respondent known to the complainant prior to the incident?

Yes

Potential witnesses to the incident

Name and Contact Information (Phone, Email)

Does the complainant wish to notify law enforcement at this time?

Yes

If law enforcement was already notified, which agency was notified (check all applicable)?

LRU Security

Hickory Police Department

Other