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This form is used to report information necessary to initiate an investigation of alleged bias, discrimination, harassment, sexual or gender-harassment, domestic or dating violence, stalking or retaliation pursuant to the Universities' Equal Opportunity, Diversity and Affirmative Action Plan ("EO Plan") and/or the Student Code of Conduct. All reasonable efforts will be made to maintain the involved parties' confidentiality during the investigation and resolution procedure.

Salem State University is committed to addressing incidents of bias and appreciates your help in bringing these incidents to our attention. This form can be completed by victims of bias-related incidents, witnesses to them or by staff or faculty members to whom others have reported the incidents. Please include as much information as possible. All reports will be kept confidential to the extent possible; you also have the option to file the report anonymously. If you wish to be contacted, please include your name and contact information at the beginning of the form.

It is unlawful to retaliate against a student, employee or any other person affiliated with the University for filing a complaint or for cooperating in an investigation of a complaint.

All parties to a complaint may have a personal advisor (for union employees this may be a union representative) assist them throughout the process, in accordance with Sexual Violence Policy, Student Code of Conduct and applicable collective bargaining agreements.

If the incident you are reporting is an emergency, please contact the Campus Police immediately at 978-542-6111 or 911 from a cell phone or non-university.

Relationship to University
Relationship to University
Type of alleged discrimination or discriminatory harassment
Type of alleged sexual violence or other prohibited conduct
Please list the sequence of events, including dates, if possible, and any relevant facts, statements and/or evidence currently known to you.
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