Please use this form to report an allegation of sex/gender-based discrimination, sex/gender-based harassment, sexual harassment (including sexual assault, dating violence, domestic violence, and stalking), sexual misconduct, or retaliation which are prohibited by Title IX and DHS policy.
This form is meant for use by students, parents or guardians, and members of the public. DRS personnel, vendors, consultants, and contractors are required to use the "Mandatory Procedure for Reporting a Complaint" protocol outlined in the IDHS Title IX Procedure Manual. Only a student, parent or guardian, or member of the public may choose to report an allegation anonymously using this form. Our ability to properly investigate an allegation depends on the information provided, so please provide us with as much information as you're able to.
We are not able to guarantee that your report will remain confidential. In certain instances, we may be required to disclose it by law.
You do not need to answer every question to submit the form. If you have any questions, please call the Title IX Coordinator at 217-606-9056 or email DHS.DRS.TitleIXCoordinator@illinois.gov.
I am a:
May we contact you for further information?
Type of complaint:
Date of incident:
Time of incident:
Location of incident:
Description of incident:
Witness names and contact information:
Were police notified?
Was medical care required or received?
Does evidence exist (e.g., texts, photos, video)?
If so, please keep those materials.
Person you believe was harmed:
What school do they attend:
What grade are they in:
Additional persons who you believe were harmed:
Person you belive caused harm:
The person is a:
Someone from outside the school
If a student, what grade are they in:
If a staff member, what is their role at the school:
(e.g., principal, teacher, security guard, or coach)
Additional persons who you believe may have caused harm:
Is there anything else you would like to let us know:
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
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