LGBTQ+ Requests/Incident Report Form

This form is used to submit requests and/or report incidents at the college. Any IVC students, faculty and/or staff as well as the community at-large are welcome to submit any requests. Please note that all information included in this form will remain confidential and will only be accessed by the IVC LGBTQ+ designee(s).

What would you like to do or know?

What would you like to do or know? Report an incident of bullying, harassment or intimidation that was directed at someone because of their real or perceived sexual orientation or gender identity. Recognize someone for positive actions Receive more information on this program or others that help make IVC a safer and more positive place to learn and work. Receive assistance on a project or request an appearance at a public meeting or event.
What do you need assistance with?

What do you need assistance with? Report an incident of bullying, harassment or intimidation that was directed at someone because of their sexual orientation, gender identity, or expression? Receive more information about support services for LGBTQ+ self-identified or questioning students, employees and/or community members? Receive assistance on event planning and/or other services?
Please describe your request/report in detail. (This is confidential information and will only be reviewed by designee(s))
Name (You can skip this item if you prefer to remain anonymous.) Name (You can skip this item if you prefer to remain anonymous.) First Last
Enter your first name , then your last name. If you prefer to remain anonymous, then move on to the next field.
Please provide an email address if you prefer being contacted in this manner.

Enter the email address you use most often.
Please provide a telephone number if you prefer being contacted by phone. Please provide a telephone number if you prefer being contacted by phone. - ### - ### ####
What is your gender identity?

What is your gender identity? Gender Non-Binary Gender Non-Conforming Genderqueer Trans* Androgyne Intergender Pangender Gender Questioning Gender Fluid Xgender Man Woman Another Identity/Decline to state
What is your sexual orientation?

What is your sexual orientation? Bisexual Asexual Homosexual Heterosexual Pansexual Polysexual Another Sexual Orientation/Decline to state
Are you a:

Are you a: Student Faculty Staff Community member
Any additional questions or information related to your report/request, please include them here.