Sex and Gender-Based Discrimination and Harassment Referral Form

Rollins College takes incidents of sex-based discrimination and harassment seriously and is required to investigate allegations of to the best of its ability. By submitting this report, you are stating that all information contained in the report is true and correct to the best of your knowledge. Knowingly providing false information may result in disciplinary action. The College prohibits retaliation for making a good faith report of sex-based discrimination and harassment. Retaliation should be reported immediately to the Title IX office.

All faculty and staff (with the exception of confidential resources in the Wellness Center, the Dean of Religious and Spiritual Life, and designated confidential faculty) are obligated to report information to the Title IX Coordinator (407-691-1773 or titleix@rollins.edu ) if they receive notice of an incident of sex or gender-based discrimination or harassment. Required reporters must not submit this form anonymously. Student reporters or reporting parties may remain anonymous; however, the College may be limited in its ability to respond to anonymous reports where the identity of those involved is unknown.

Enable additional features by logging in.

Your full name:

Affiliation to Rollins:

Learn more

Faculty, staff, student, alumni, third-party contractor, visitor, parent, unaffiliated, etc.

Your phone number:

Your email address:

Email address must be of a valid format.

Your R-number:

Reason for this report(Required):

This field is required.

Learn more

Select to the best of your ability

Date of incident(Required):

This field is required.

Learn more

There is no time-limit for reporting. If unknown, list date you learned of incident.

Time of incident, if known:

Learn more

Select a time of day to the best of your knowledge.

Location of incident(Required):

This field is required.

Specific location, if known:

Learn more

Room/office number or other information.

Involved Parties

Please share information about any individuals involved in the incident.

Reporting party refers to any person(s) who may have been subjected to harassment or discrimination.

Responding party refers to the person(s) or organization accused of committing harassment or discrimination.

Witness refers to any person(s) who may have directly observed an incident or have direct or indirect knowledge related to an incident of harassment or discrimination.

Name of Individual or Organization

Gender Identity

Role within Incident

R-Number (if known)

Phone Number (if known)

Email Address (if known)

Affiliation to Rollins (student, faculty, staff, alumni, third-party contractor, unaffiliated, etc.)

Incident Information

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Involved Parties

Incident Information

Supporting Documentation

Submission