Today's Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20172018201920202021 Year Reporter's Name (Optional) First Last Nature of Report * - Select -sexual assaultdating violencestalking Victim(s) Name (optional) Gender of Victim * Male Female Victim's Affiliation to UNT Dallas * student faculty staff not affiliated other I (the reporter) would like to be contacted by someone from the following UNT Dallas Offices (please check all that apply) Counseling center Office of the Dean of Students UNT Dallas Police Department Equal Opportunity Compliance Officer Title IX Coordinator I don't want to be contacted Phone Number Email Name of Assailant(s) Gender of Assailant(s) Male Female Multiple Males Multiple Females Males and Females Unknown Assailant(s) Relationship to Victim Partner, girlfriend or boyfriend Friend Ex-partner, girlfriend or boyfriend Faculty Teaching Assistant Staff Member Work Supervisor Colleague or Co-worker Acquaintance Stranger Other Assailant(s) use of alcohol or drugs Used Alcohol Used drugs other than alcohol Unknown whether drugs or alcohol were used Assailant(s) affiliation to UNT Dallas Student Faculty Staff Not Affiliated Unknown Other Date of Incident * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year Time of Incident * Hour123456789101112 Hour :Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Minute am pm Location of Incident Victim's Room Assailant's Room Workplace Campus Building Car/Vehicle Residence Hall Off- Campus Apartment/House Outdoors Parking Lot Which Campus Building? Building Name Name of Residence Hall Name of Residence Hall Was Victim given alcohol and/or other drugs without consent or knowledge? Yes, alcohol Yes, drugs No Unknown If alcohol and/or drugs were involved, did the victim feel pressure to consume or use? - None -YesNo Was incidnet previously reported to a campus department or external agency? * - Select -YesNoUknown If yes, please identify the department or external agency informed and the date notified: * Please provide a detailed description of the incident: * Has the victim received any additional recources (i.e. counseling or medical attention)? Submit
