Your Information

First Namerequired

Last Namerequired

Position/Department

Emailrequired

Phonerequired

Reported to you by: (Select one)*

Victim Witness Third-party Anonymous

If you wish to avoid specifics, choose one of the options in the drop down menu below. Please refer to the location descriptions below this form for proper classification.

Please describe the incident in as much detail as possible.

Do you have reason to believe this incident represents a present threat of harm or danger to the victim or other member(s) of the community?

Yes No

If yes, why?

Was a weapon involved?

Yes No

Number of assailants/perpetrators:

If single assailant/perp, provide as much description as possible including gender, race, age, height, weight, etc.

Name of alleged assailant(s) if known*:

Other departments or individuals to whom the victim/reporter has reported this incident

Name of reporting victim *

Names and contact information for any relevant witnesses *

* Any field denoted with an asterisk is a field that may be left blank by you if you intend for this report NOT to serve as actual notice to the university of harassment, discrimination, sexual assault or other civil rights violation for which notice will trigger an obligatory investigation by the university. Some employees are required to complete this form in full, while others may withhold from the fields designated with an *, depending on your role. Training has been provided on what you are required to report, but if you are unsure, please consult with your supervisor.