| Reporting Form |
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| Confidentiality Statement |
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If this is an emergency, please call 911 immediately.
In order to protect your need for confidentiality, we can only provide general, rather than personal, information through this website. If we receive information requiring more in-depth, complex responses, we will refer you to resources who can help you in person. If we receive information requesting no further action, please be aware that we do have a legal obligation to respond institutionally to situations that may threaten the safety of the individual who is requesting information, or of others.
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| Information About the Incident |
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Date of Incident:
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Year: |
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Location:
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Please be as specific as possible (cross streets, name of school, etc.) |
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Type of Offense:
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To select more than one, press CTRL while selecting. |
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If other, please identify:
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Perceived Bias Motive:
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To select more than one, press CTRL while selecting. |
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Did you seek treatment?:
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Were you injured?:
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If so, how?:
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To select more than one, press CTRL while selecting. |
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Please Describe:
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What Happened:
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Offender Acted:
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Did you report this incident?
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If so, whom did you report to?
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For example, friend, family, faculty, police, etc. |
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How did they respond?
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May we follow up on this report?
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If so, who would you like to contact you (you may select more than one)?
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Gender Equity Resource Center
Tang Center
Student Advocate Office
UC Police Department |
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| Information on the Offender |
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Name:
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Race/Ethnicity:
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If other, please identify:
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Age:
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Gender:
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Sexual Orientation:
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Religion:
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Please list any disabilities:
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Offender's Relation to Victim:
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| Information on the Victim |
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Name:
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Race/Ethnicity:
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If other, please identify:
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Age:
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Gender:
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Sexual Orientation:
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Religion:
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Please list any disabilities:
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Offender's Relation to Victim:
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| Information About You |
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Name:
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Note: If you wish to remain anonymous, do not give your name. |
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E-Mail Address:
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Phone Number:
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Note: If you would like us to follow-up with your report, please provide an e-mail address or phone number. |
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Are you a:
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If other, please identify:
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Are you a:
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If other, please identify:
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If you are requesting follow-up, please fill out your name and phone number or e-mail at the top of this form.
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