Gender Violence Report Form : Campus Gender Violence Project : UVM Women's Center : University of Vermont

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Gender Violence Report Form

Gender Violence Report Form

If you become aware of an incident of sexual violence, relationship violence or stalking, UVM policy calls for UVM Victim’s Advocate to be notified of the indcident. All incidences of gender violence experienced by a UVM student, staff or faculty member during their time at the University should be reported either by calling the Victim's Advocate at (802) 656-7892 and/or by completing and submitting this form. All reports are confidential, information is used for statistical reporting required of the Campus Advocacy Program by the University, and non-identifying information will also be reported to the UVM Police for statistical purposes.

Reporter's NameReporter's Department

Reporter's PhoneReporter's Email

Date Survivor Disclosed to You

Survivor Information

Survivor's Affiliation to UVM Student StaffFacultyOther

Gender of Survivor

Month/Year of Incident/s (approximate if unknown):

Age of Survivor (approximate if unknown):

Location of Incident:

On Campus Residence Off Campus Residence On Campus Public Location Off Campus Public Location

UVM Affiliated Building, non-residence (eg. education/admin building, Fraternity/Sorority House)

Other

Nature of Incident: (check all the apply)

Sexual Assault, if sexual assault, check one of the following:

Penetration
Unwanted sexual contact which did not involve penetration
Unknown

Sexual Harassment

Stalking

Relationship Violence, if relationship violence, please check all that apply

Psychological/Emotional
Physical
Sexual

Was the victim under the influence of any substances at the time of the incident?

Yes (If yes, voluntary, involuntary, unknown) No Unsure

If known, what substance/s?

Has the victim been referred to/given information about the Victim's Advocacy Services? Yes No

Has the victim been connected with Victim's Advocacy Services (by phone and/or in person)? Yes No

If known, what other services has the victim connected with? (please list)

Offender Information

Gender of Offender

Offender affiliation to UVM? Student StaffFacultyOther

Was the offender under the influence of any substances at the time of the incident? YesNoUnsure

If known, what substance/s?

Relationship of Offender to Victim

Acquaintance
Friend
Current Partner
- Married/Civil Union
- Live Together
Ex-Partner
- Divorced
- Live together
Coworker
Professor
Roommate
Stranger
Relative
Staff Member
Classmate
Unknown
Other

Last modified July 16 2008 02:11 PM