University of Michigan - Flint

Gender Violence Incidents

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.

If you checked "other" please describe here.

Location of Incident:

If you checked "other" please describe here.

Gender of Survivor:

Age of Survivor:

Survivor's Affiliation to UM-Flint

If you checked "other" please describe here.

Where does the survivor live?

Number of perpetrator(s):

Gender of perpetrator(s):

Relationship of perpetrator(s)to suvivor:

If you checked "other" please describe here.

Is/are the perpetrator(s)?

If you checked "other" please describe here.

Was the incident reported to police agency?YesNoUnknown

Would you like the WEC Sexual Assault Advocate to contact you regarding this report?YesNo

If yes, please provide either e-mail address and/or phone number:

Report submitted by:(optional)

Title/address/phone number/e-mail