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Sexual Misconduct, Intimate Partner Violence and Stalking Reporting Form

If you need to report an emergency, do not use this form. Instead, call the Police Department at 911.
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This form should be used to report allegations of sexual misconduct to the University of North Texas Health Science Center Title IX Coordinator. Reportable offenses include allegations of sexual harassment, sexual assault, dating violence, domestic violence, stalking, sexual coercion, sexual exploitation and any retailiation as defined by state and federal law, and/or HSC policy. You may view the policy at HSC's Title IX Policy 1.107

To report any other forms of discrimination, please use the reporting form found here

If you or someone you know is an HSC student or employee and would like to speak to, receive support or information related to issues of sexual violence, relationship violence, stalking, or discrimination, you may contact the following:

UNT HSC's Title IX Coordinator at titleix@unthsc.edu
UNT HSC's Survivor Advocate at survivoradvocate@unthsc.edu
HSC Care Team: 817-735-2740 or careteam@unthsc.edu
HSC Human Resources at HSC.HR@unsystem.edu
HSC Student Health Services: 817-735-5051 or StudentHealth@unthsc.edu
UNT System Office of Equal Opportunity: HRS.EO@untsystem.edu
Employee Assistance Program (EAP) - Alliance Work Partners: 800-343-3822 or https://www.awpnow.com
HSC Trust Line link is www.unthsc.edu/letstalk | (844) 692-6025
Additional resources can be found at https://www.unthsc.edu/care-and-civility/resources/

Employees may not report anonymously and must inform the Title IX Coordinator of all reports or knowledge of suspected misconduct. The Title IX Coordinator can be contacted at titleix@unthsc.edu. Please know that anonymous reports may impair, limit, or delay UNT HSC's ability to take appropriate action on the report.

If you need assistance completing this form or an alternate format, please contact Title IX Coordinator, Dr. Maureen McGuinness at titleix@unthsc.edu or 817-735-5919.

Most UNT HSC employees are obligated to report Title IX incidences to the Title IX Coordinator and cannot promise confidentiality, but they can promise privacy. If a complainant would like to speak to a Confidential Employee who will remain confidential, please consider contacting any of the following HSC resources:

TELUS Health Student Support Program: 866-743-7732
Student Health: 817-735-5051

For off-campus confidential resources please contact the following:

The Women's Center of Tarrant County - 817-927-4040

One Safe Place of Tarrant County 817-916-4323

Hospitals and Law Enforcement Agencies

Baylor Hospital (Fort Worth): 817-926-2544

Harris Methodist Hospital (Fort Worth): 817-250-2000

John Peter Smith Hospital (Fort Worth): 817-702-2839
Fort Worth Police Department (non-emergency): 817-335-4222

Background Information

Please fill out the following information to the best of your knowledge.

Definition of Roles

Complainant: means an individual who may have been the subject of conduct prohibited under this policy regardless of whether or not the individual reports the conduct.

Respondent: means an individual identified as possibly having engaged in conduct prohibited under HSC policy.

Witness: An individual who has a first-hand account of the alleged behavior

Bystander: An individual who has a first-hand account of the alleged behavior and who may have tried to intervene to stop the alleged behavior

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Your full name:

Your position or title:

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Please report if you are a student, faculty, staff, or non-affiliate.

Your phone number:

Your email address:

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Respondent's relation to HSC(Required):

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Nature of Report(Required):

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Date of incident(Required):

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If you do not know date of incident, please list date reported to you

Time of incident:

Location of incident(Required):

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Please determine location to the best of your knowledge.

Involved Parties

To the best of your ability, please list any party that may be involved:

First and Last Name

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ID Number

Phone number

Email address

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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. 5GB maximum total size.
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Background Information

Involved Parties

Report Information:

Supporting Documentation

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