Wilkes University

Gender-Based Discrimination and Harassment Reporting Form

Do not use this form to report events presenting an immediate threat.

If you require emergency assistance, please contact the Department of Public Safety at (570) 408-4999 or call 911.

This form is designed for students, faculty, staff, visitors and others to report incidents of sex or gender-based harassment and discrimination (including sexual harassment, sexual misconduct, relationship violence, retaliation, pregnancy discrimination, and stalking or bullying on the basis of gender) to the University. The University’s Title IX Coordinator receives and reviews all complaints and routes them to the appropriate university administrator for investigation.

This form can be used by any person making a report on his or her own behalf who wishes to remain anonymous. It can also be used to anonymously file a report on behalf of another person. It is important to understand that if you choose to file an anonymous report, you may limit the University’s ability to remedy the problem.

The University will make every effort to protect the privacy of all involved, but the information you provide in completing this form is not confidential and may be shared as necessary for the University to take the appropriate action.

Gender-Based Discrimination and Harassment Reporting Form

Gender-Based Discrimination and Harassment Reporting Form


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  • Phone Number - -
  • Preferred method of contact
  • Your affiliation with Wilkes University*
  • You are making this report*
  • Date of incident of concern
  • Do you believe that this incident was prompted because of a protected characteristic other than sex or gender?*
  • Other people or places that know about this incident (Check all that apply)
  • By submitting this form you indicate you understand that:
    - If you provide your name you may be contacted by Wilkes University's Title IX Coordinator or designee to confirm receipt of the report and to determine if you need further information or assistance.
    - Information provided in this form will be used to assist Wilkes University to accurately report the number of incidents occurring on Wilkes University owned and controlled areas.

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Although the university cannot commit to keeping a complaint of discrimination confidential because of the university’s obligation to investigate the complaint, the university will use its best efforts not to disseminate information concerning the complaint beyond those who have a need to know.