Survivor: Sexual Violence Disclosure Form

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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

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