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- Anonymous Report Form for Sexual Assault and Misconduct
- Anonymous Reporting

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Home » Police Department » Reporting a Crime

Anonymous Report Form for Sexual Assault and Misconduct

Today's Date *

Month

Day

Year

Reporter's Name (Optional)

Nature of Report *

Victim(s) Name (optional)

First and Last

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)

First and Last

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 *

Month

Day

Year

Time of Incident *

Hour

:

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?

Was incidnet previously reported to a campus department or external agency? *

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)?

Office of Student Affairs

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Dallas, Texas 75241
200
Founders Hall (B2)
972-338-1775
StudentAffairs@untdallas.edu

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