Discrimination & Harassment Incident Report

This form may be completed by any member of the DigiPen community who has experienced or otherwise become aware of an incident that may constitute a violation of DIT Policy on Harassment and Nondiscrimination.

To report a potential violation, please complete the form below.

If you have any questions or concerns please email titleix@us.digipen.edu.

1Information about the Reporter

2Information about the Victim/Survivor

3Information about the Offender

4Information about the Offender (cont'd)

5Incident Description

6Review Your Entry

Name of Reporter Name of Reporter * First Last
Race (if relevant to the report)
Sexual Orientation (if relevant to the report)
Gender Identity (if relevant to the report)
Email *
Date of Incident Date of Incident * / MM / DD YYYY
Identity of Reporter

Identity of Reporter Victim/Survivor Spouse Friend Roommate Faculty or Staff Colleague Witness or observer Other Other
Time of Incident Time of Incident : HH MM AM/PM
Location of Incident *

Location of Incident On Campus Off Campus DigiPen Housing
Where did the incident take place? Please be specific. *

Example: bookstore, shuttle, DigiPen Housing, parking lot, class, etc.
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.