Incident Report Form
Discrimination, Sexual Misconduct/Harassment/Assault
The university has an expectation that employees will share information they receive about campus incidents and for student incidents occurring on or off campus. Students and guests on campus are encouraged to report any incidents using this form. The form is intended to convey information needed to assess the danger, action to be taken and track incidents.
Instructions: For purposes of follow-up, all fields must be completed. Give as much information as necessary when completing descriptions. The form should be completed and submitted within 24 hours of becoming aware of any report.
Reported to you by:
Date of Incident:
Where did the incident occur?
Please describe the incident in as much detail as possible:
Do you have a reason to believe this incident represents a present threat of harm or danger to the victim or other member(s) of the community?
Yes, please describe why
Was a weapon involved?
Do not know
Number of offenders:
Role of offender(s) on campus:
no campus role
Name of offender(s):
Was there any evidence that this incident was motivated by the victim's (check all that apply)?
sex (including pregnancy)
Other departments or individuals to whom the victim/or you have reported this incident:
Name of victim:
Names and contact information for any relevant witnesses:
Do Not Fill This Out