Anonymous Report Form

To anonymously report an incident(s) of sexual misconduct to the College’s Title IX Coordinator, please complete the form below. Please see Board Policy 3020 for the definitions of policy violations and procedures regarding the College’s response to reports of sexual misconduct.

1. Have you been the victim of Dating Violence, Domestic Violence, Sexual Assault, Sex/Gender Harassment, Sexual Violence, Stalking, or Retaliation for reporting a violation of the College’s sexual misconduct policy? If yes, please select all that apply.

1. Have you been the victim of Dating Violence, Domestic Violence, Sexual Assault, Sex/Gender Harassment, Sexual Violence, Stalking, or Retaliation for reporting a violation of the College’s sexual misconduct policy? If yes, please select all that apply. Dating Violence Domestic Violence Sexual Assault Sex/Gender Harassment Sexual Violence, Stalking Retaliation Other (please describe): Other (please describe):
2. If yes, please provide the name and status of the alleged perpetrator:
Name
Status

Status Student Staff Faculty Non-Student Unknown
3. Are you reporting on behalf of another person who has been the victim of dating violence, domestic violence, sexual assault, sex/gender harassment, sexual violence, stalking, or retaliation for reporting a policy violation? If so, please provide their name and select all applicable violations:
Name
Applicable Violations

Applicable Violations Dating Violence Domestic Violence Sexual Assault Sex/Gender Harassment Sexual Violence, Stalking Retaliation Other (please describe): Other (please describe):
4. Are you or the person on whose behalf you are reporting a minor (under age 19)?

4. Are you or the person on whose behalf you are reporting a minor (under age 19)? Yes No
5. Please select the status that best describes you:

5. Please select the status that best describes you: Student at PSC Faculty/Staff at PSC Unaffiliated with PSC Prefer not to disclose
6. Please enter a description of the incident, including the date, time, and location.
7. If there were witnesses to the incident(s), please provide their name and contact information, if known:
8. Was law enforcement contacted?

8. Was law enforcement contacted? Yes No
The safety and well-being of students and employees is a top priority and the College strives to provide an environment in which students and employees are free from unlawful harassment or discrimination. Please understand that an anonymous report limits the College’s ability to respond fully to the report. You are encouraged to contact the Title IX Coordinator, Eulanda Cade, and disclose your name so that the College can best assist you. You can reach Ms. Cade at 402-872-2230 or ecade@peru.edu.

Below are resources that may be helpful to you.

Campus Security
Should you or any student ever feel unsafe on campus, please do not hesitate to contact the Security Office. Additionally, security escorts on campus are available. The Security Office is located in the Campus Services Building, Room 228 and can be reached at 402-872-2411. Local law enforcement can also be contacted for assistance.

Counseling Services
Peru State College offers free, confidential counseling services. The Counseling Services Office is located in the CATS 202 office suite on the top floor of the Center for Achievement and Transition Services. The phone number is 402-872-2436.

Academic Assistance
Student Success Services provide services to promote academic success. More information is available by contacting Peggy Groff, Student Success Coordinator, at 402-872-2438, or by visiting www.peru.edu/trio

Disabilities Services Office
The Disabilities Services Office provides a variety of supplemental information including; Disability Laws and Regulations, Types of Accommodations, and Peru State College’s Academic Policies related to receiving accommodations. You can learn more by contacting Mr. Matt Thielen, Dean of Student Life at 402-872-2246, or by stopping in the Student Center, Room 114.
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