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Sexual Misconduct

This form provides preliminary information to the Title IX Office to assist in resolving incidents or alleged violations of sexual misconduct that include but not limited too, sexual harassment, sexual assault, dating violence, domestic violence, and stalking. This form can be utilized by anyone wishing to file a report on their own behalf or by anyone wishing to file a report on behalf of a Florida Polytechnic University community member.

This form is designed to provide students, employees, faculty, vendors, visitors, or others with an on-line method to report specific information related to an alleged incident(s) of sexual misconduct.

You are not required to complete the entire form in order for the complaint to be submitted. The institution will use the information provided to begin a process, which may include contacting the complainant, respondent, and/or any potential witnesses. However, if the report does not contain specific information, the institution's investigation and response may be limited.

Once you submit this report you may be contacted by someone from the Title IX Office if additional information is needed. Regardless of the nature of your report, the university will ensure that your information is forwarded to the office with responsibility for investigating and addressing complaints, reports, or concerns as appropriate, based on the information you have provided. The information you provide will be kept confidential to the extent permitted by law.

Please note that submissions using this form are not being reviewed outside of normal business hours.

If you have questions, please contact our Title IX Coordinator, Michelle Disson, at titleixcoordinator@floridapoly.edu or by phone at 863-874-8484.

This Reporting Form is NOT a 911 or Emergency Service:
Do not use this site to report events presenting an immediate risk to health or safety.
If you require emergency assistance, please contact Florida Polytechnic University Police Department at 863-874-8472 or dial 911.

Background Information

NOTE: If you wish to submit a complaint for yourself anonymously and you are not a Responsible Employee, you may omit your contact information, please note that reporting anonymously may limit the University's response.

Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Name or Organization

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Incident Specific Information

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 1 GB maximum total size. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report