Sexual Misconduct Initial Report Form

Your Contact Information

Please identify your relationship to the university: Student Employee Other

If other (Please Explain)

Name

Are you reporting for yourself?   Yes No

Contact Information for Victim

Complainant/Victim is a : Student Graduate Student Staff Faculty Other

If other (Please explain)

Name

Contact Information

Contact Information for Respondent/Accused

Respondent/Accused is a:  Student Graduate Student Staff Faculty Other

If other (Please explain)

Name (If known)

Contact Information (If known)

Reporting

Where the incident occurred?

If other (Please explain)

Incident occurred within a residence hall? No Yes

Date and Time of Incident

You are reporting:

Please describe, with as much detail as possible, the incident you would like to report: If you are uncomfortable in adding this information, you may type "Would like to speak to someone".

Certification

If you would like a copy of this form, please provide your email.

Signature (Type your name)

By submitting this form I am certifying the above statements to be true and factual to the best of my knowledge.

Submit