Confidential Report Form

Sexual Misconduct, Dating/Relationship Violence, Stalking Form

Background Information

Your Full Name:

Your position/title:

Your phone number:

Your e-mail address:

Your physical address:

Date of Incident: (required)

Time of Incident: (required)

Location of Incident: (required)

Specific Location: (required)

Involved Parties

Name or Organization:

Gender

Select Role

Phone number:

Email address:

Name or Organization:

Gender

Select Role

Phone number:

Email address:

Name or Organization:

Gender

Select Role

Phone number:

Email address:

Questions

The following information is needed to proceed with an investigation that could lead to student or employee discipline. Information must be truthful; any individual knowingly providing false information may be subject to disciplinary sanctions and legal action. Complaints that are later found not to violate policy are not assumed to be false.

PLEASE PROVIDE AS MUCH FACTUAL DETAIL AS POSSIBLE (WHO, WHAT, WHERE, WHEN, HOW IT HAPPENED): (required)

DID THE INCIDENT INVOLVE A SEXUAL ASSAULT? Policy definition: actual, attempted, or threatened sexual act without that person's consent that includes, but is not limited to: 1) Involvement without consent in any sexual act in which there is force, expressed or implied, or use of duress or deception upon the victim. Forced sexual intercourse is included in this definition, as are the acts commonly referred to as "date rape" or "acquaintance rape." This definition includes coercing, forcing or attempting to coerce or force sexual intercourse or a sexual act on another. 2) Involvement in any sexual act when the victim is unable to give consent. 3. Intentional and unwelcome touching, or coercing, forcing, or attempting to coerce or force another to touch a person's intimate parts (defined as primary genital area, groin, inner thigh, buttocks, or breast). 4. Offensive sexual behavior that is directed at another such as indecent exposure or voyeurism. CONSENT is informed, freely given and mutually understood. If coercion, intimidation, threats, and/or physical force are used, there is no consent. If the complainant is mentally or physically incapacitated or impaired so that the complainant cannot understand the fact, nature, or extent of the sexual situation, there is no consent; this includes conditions due to alcohol or drug consumption, or being asleep or unconscious. Silence does not necessarily constitute consent, and past consent of sexual activities does not imply ongoing future consent. Whether the respondent has taken advantage of a position of influence over the complainant may be a factor in determining consent.

Yes

No

Not Sure

DID THE INCIDENT INVOLVE DATING OR RELATIONSHIP VIOLENCE? Definition: Physical harm or abuse, and threats of physical abuse, arising out of personal intimate relationship. This violence may also be called domestic abuse or spousal/partner abuse and may be subject to criminal prosecution under Minnesota state law.

Yes

No

Not Sure

DID THE INCIDENT INVOLVE STALKING? Definition: Conduct directed at a specific person that is unwanted, unwelcome, or unreciprocated and that would cause a reasonable person to fear for her or his safety or the safety of others or to suffer substantial emotional distress.

Yes

No

Not Sure

DID THE INCIDENT INVOLVE NON-FORCIBLE SEX ACTS? Definition: Unlawful sexual acts where consent is not relevant, such as sexual contact with an individual under the statutory age of consent, as defined by Minnesota law, or between persons who are related to each other within degrees wherein marriage is prohibited by law. INDICATE OTHER OFFICES OR AGENCIES INFORMED OF THE INCIDENT?

Yes

No

Not Sure

PLEASE PROVIDE ANY ADDITIONAL INFORMATION THAT MAY BE HELPFUL:

Supporting Documentation

Photo File Upload Supporting documents may be attached below. Must be less than 20 mb, and .jpg, .gif, .pdf or .png format.