Is this report for: Information Only
Action
Date of Incident (mm/dd/yyyy):
Time of Incident (please specify am/pm):
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Location of Incident:
*If this incident occurred outside of Kittitas County, advocacy and support services are still available
PERSONAL INFORMATION
The person making this report is:
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Status
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Gender
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Sexual Orientation
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ABOUT THE INCIDENT
The incident was: (check all that apply)
The incident occurred because of:
Did you report this incident to the police? yes No
If no, what were the reasons for not reporting? If yes, what was the response/action?
Were you satisfied with the response/action? yes No
Why or why not?
Was this incident reported to any other campus agency or department yes No
If no, what were the reasons for not reporting? If yes, what action was taken? Was this satisfactory?
Why or Why not?
ALLEGED PERPETRATOR INFORMATION
Number of Alleged Perpetrators:
Gender of Alleged Perpetrator: Male
Female
Unknown
Other
Relationship to Victim:
Please describe the incident:
Ethnicity
Were there any witnesses? yes No Don't know
ABOUT YOU
In your opinion, how do you think this matter should be addressed by the University:
You may choose to give your name or to be anonymous. If you would like the Incident Response Coordinator to help you explore your options, look at ways to help resolve the situation or proved you with advocacy and support, please leave your name and phone number, or list another way to contact you.
Name:
Phone:
Email:
Other:
