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Gender Violence Incidents
Gender Violence Incident Report Form
Gender Violence Incident Report Form
Date of Incident:
Time of Incident:
Type of Incident:(highlight as many as apply) to highlight more than one selection hold the "control" key.
Please select...
Sexual Contact (intentional touching of intimate parts for the purpose of sexual arousal or gratification without consent)
Penetration (sexual intercourse, cunnilingus, fellatio, anal intercourse, and any other intrusion of a body part or an object into genital or anal openings) without consent.
Dating/ Domestic Violence
Stalking
Sexual Harrassment
Other - please describe
If you checked "other" please describe here.
Location of Incident:
Please select...
Residence Hall
Campus Building
Parking Lot/structure
Sorority House (off campus)
Fraternity House (off campus)
House/ apartment (off campus)
Other
If you checked "other" please describe here.
Gender of Survivor:
Age of Survivor:
Survivor's Affiliation to UM-Flint
Please select...
Undergraduate Student
Faculty
Graduate Student
Staff
No Affiliation
other
If you checked "other" please describe here.
Where does the survivor live?
Please select...
Residence Hall
Off-campus apartment/house
Family home
Number of perpetrator(s):
Gender of perpetrator(s):
Relationship of perpetrator(s)to suvivor:
Please select...
Acquaintance
Roommate/suitemate/housemate
Family member
Stranger
Partner/spouse/significant other
Faculty or staff member
Other
If you checked "other" please describe here.
Is/are the perpetrator(s)?
Please select...
Student
Faculty
Staff
Not affiliated
Unknown
Other
If you checked "other" please describe here.
Was the incident reported to police agency?
Yes
No
Unknown
Would you like the WEC Sexual Assault Advocate to contact you regarding this report?
Yes
No
If yes, please provide either e-mail address and/or phone number:
Report submitted by:(optional)
Title/address/phone number/e-mail
Need assistance with this form?
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Drugs commonly used to incapacitate people in order to sexually assault them include:
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