Sexual Assault Reporting Form

Sexual Assault Reporting Form

This form is designed to facilitate the anonymous report of a sexual assault to assist Southwest Technical College in understanding current sexual violence trends at our campus. Filing this form will not result in an investigation unless the victim later decides to make a formal report to law enforcement. Completing this form does not constitute a police report nor a student conduct report. You will not be contacted by the college unless you indicate a desire to be contacted (you may request to be contacted at the end of this form).
Number of Victim(s)*
Gender of Victim(s)
Victim's Affiliation to Southwest Tech*

Current STECH StudentFormer STECH StudentSTECH FacultySTECH Staff or AdministrationNot AffiliatedUnknownOther
Number of Offender(s)
Gender of Offender(s)
Offender's Affiliation to Southwest Tech*

Current STECH StudentFormer STECH StudentSTECH FacultySTECH Staff or AdministrationNot AffiliatedUnknownOther
Date of Incident

MonthDayYear
Date
Approximate Time of Incident

Hour Minutes

AM/PM Option
Location of Incident
(Address preferred, but street coordinates are acceptable.)
Was coercion or force involved? (Check all that apply)

Verbal pressureIntimidation or cercionThreats to harmPhysical force/assault (pushing, etc.)Incapacitation due to drugs/alcoholAbuse of authority (supervisor, etc.)Use of a weaponThreat of a weaponUse of drugs/alcohol by offenderUse of drugs/alcohol by victimSuspected use of predatory drugsSexual contact with no penetrationSexual contact with penetrationEmotional/verbal abuseOther
Note: An incident does not have to involve coercion or force to be considered a student conduct violation. Reporting alcohol or drug use here will not result in any sanctions for the victim.
Please give a description of the incident:
If a victim wishes for the assault to be recorded in college statistics, this section needs to be completed.
To the best of your knowledge, has this incident been reported to the police?
Would you like to have the Title IX Coordinator contact you?*
Please remember if you click no and choose to be anonymous, this will limit our ability to investigate and respond. This contact is confidential. You can receive further information about resources and options; counseling for survivors, their friends and support persons; and advocacy for survivors who choose to contact other agencies. Please add your contact information below if you wish to have the Title IX Coordinator contact you.
Contact Information (Not required if reporting anonymously)

First NameLast Name
Email (Not required if reporting anonymously)
example@example.com
Phone Number (Not required if reporting anonymously)
Please enter a valid phone number.
Verification:*
Should be Empty: