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Sexual Violence
Survivor: Sexual Violence Disclosure Form
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Survivor: Sexual Violence Disclosure Form
Please don't fill out this input box.
Reporter's Name
Reporter's Phone Number
Reporter's Email Address
Campus status of Reporter
Please Select
Student
Faculty
Staff
Survivor's Name
Survivor's Phone Number
Survivor's Email Address
Type(s) of Sexual Violence Experienced
Cyber Harassment
Dating Violence
Domestic Violence
Indecent Exposure
Sexual Abuse
Sexual Assault
Sexual Exploitation
Sex-Based/Gender-Based Discrimination
Sex-Based/Gender-Based Harassment
Sexual Harassment
Stalking
Voyeurism
Not sure...
Other
If you selected "other", please explain.
Name of Person Accused
Phone Number of Person Accused
Email of Person Accused
Please list other individuals, if any, who were involved
Other individuals may include: additional survivors, additional Person(s) Accused/Respondent(s), potential witnesses, etc. If known, please provide any contact and/or descriptive information (e.g. first name, last name, student ID number, date of birth, email address, phone number etc.) to help with identification.
Day of Incident
Time of Incident
Include a.m. or p.m.
Location of Incident
Incident Description
Actions you've taken, to date, to support the survivor
Met with student or have a scheduled time to meet
Provided referral to campus resources
Provided referral to off-campus / community resources
Called Campus Police / emergency services
No actions taken yet
Other
If you selected "other", please explain.
To which campus resources did you refer the survivor?
Academic Advising
Campus Ministry
Campus Police
Director, Human Resources
Priest / Chaplain
Psychological Services
Residence Manager
Sexual Violence Education Prevention Coordinator
Student Health Services
Student Wellness Educator
Vice Principal, Students
None
Other
If you selected "other", please explain.
What actions, if any, has the survivor taken prior to submitting this form?
Sought academic accommodations (withdrawal, course load reduction, incomplete, etc.)
Sought residence / living accomodations
Accessed campus resources
Accessed off-campus / community resources
Completed a Campus Police Report to keep on file
Consulted with Campus Police in an informal meeting about their reporting options
None
Don't know..
Other
If you selected "other", please explain.
What off-campus / community resources has the survivor accessed?
Good 2 Talk hotline
London Police
Regional Sexual Assault & Domestic Violence Treatment Centre at St. Joseph's Hospital
Sexual Assault Center London
London's ReachOUT hotline
Other
If you selected "other", please explain.
What further actions, if any, does the survivor hope to take after submitting this form?
Academic accommodations (withdrawal, course load reduction, incomplete, etc.)
Residence/Living accommodations
Access campus resources
Access off-campus / community resources
Complete a Campus Police Report to keep on file. (Campus Police must contact London Police once the survivor makes a statement)
Consult with Campus Police in an informational meeting about their reporting options
None
Don't know yet...
Other
If you selected "other", please explain.
Please provide any other information that may be helpful
Form UUID
Site Name
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