Your confidentiality and trust is very important to us! Everything submitted in this form will be used for investigative purposes only. Submitter Information: Last Name First Name SUID Victim Information: Last Name First Name SUID Affiliation: Main Campus Student UC Campus Student ESF Campus Student Faculty/Staff Community Resident Other Choose One: Classification: Freshman Sophomore Junior Senior Graduate Student Law Student Other Choose One: Optional Information: Race/Ethnicity: American Indian/Alaskan Native Asian/Pacific Islander Black Hispanic Multiracial Non-Resident / International White Other Choose One: Gender: Female Male Transgender Choose One: Sexual Orientation: Bisexual Gay Heterosexual Lesbian Other Choose One: Disability: Disabled Non-disabled Other Choose One: If Other, please specify: Are you the victim? Yes No Choose One: Accused Information: Last Name First Name Unknown Gender: Female Male Transgender Choose One: Classification: Freshman Sophomore Junior Senior Graduate Student Law Student Other Choose One: Race/Ethnicity: American Indian/Alaskan Native Asian/Pacific Islander Black Hispanic Multiracial Non-Resident / International White Other Choose One: Affiliation: Main Campus Student UC Campus Student ESF Campus Student Faculty/Staff Community Resident Other Choose One: Other Affiliations (check all that apply): Athletic or Club Sport Greek Affiliation No Known Affiliation Other Agency Recognized Student Organization Residence Hall/Floor Unrecognized Organization Other If Other, include affilation notes/details. Relationship to Victim if applicable No Relationship Co-Worker Live in same Residence Hall Classmate Supervisor Other Choose One: If there was more than one offender please continue below; otherwise, click here to go to event information. Accused Information (#2): Last Name First Name Unknown Gender: Female Male Transgender Choose One: Classification: Freshman Sophomore Junior Senior Graduate Student Law Student Other Choose One: Race/Ethnicity: American Indian/Alaskan Native Asian/Pacific Islander Black Hispanic Multiracial Non-Resident / International White Other Choose One: Affiliation: Main Campus Student UC Campus Student ESF Campus Student Faculty/Staff Community Resident Other Choose One: Other Affiliations (check all that apply): Athletic or Club Sport Greek Affiliation No Known Affiliation Other Agency Recognized Student Organization Residence Hall/Floor Unrecognized Organization Other If Other, include affilation notes/details. Relationship to Victim if applicable No Relationship Co-Worker Live in same Residence Hall Classmate Supervisor Other Choose One: If there was a third offender please continue below; otherwise, click here to go to event information. Accused Information (#3): Last Name First Name Unknown Gender: Female Male Transgender Choose One: Classification: Freshman Sophomore Junior Senior Graduate Student Law Student Other Choose One: Race/Ethnicity: American Indian/Alaskan Native Asian/Pacific Islander Black Hispanic Multiracial Non-Resident / International White Other Choose One: Affiliation: Main Campus Student UC Campus Student ESF Campus Student Faculty/Staff Community Resident Other Choose One: Other Affiliations (check all that apply): Athletic or Club Sport Greek Affiliation No Known Affiliation Other Agency Recognized Student Organization Residence Hall/Floor Unrecognized Organization Other If Other, include affilation notes/details. Relationship to Victim if applicable No Relationship Co-Worker Live in same Residence Hall Classmate Supervisor Other Choose One: Incident Information: Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 2004 2005 2006 2007 2008 2009 2010 Time of Incident A.M. P.M. Number of Witnesses Location of Incident Nature of Incident (select the one category that best represents your complaint): Phone Harassment Physical Harassment or Assault Sexual Harassment or Assault Vandalism Verbal Harassment Electronic/Written Harassment (E-Mail, Letters, Notes, etc.) Other If Other, please specify. Description: (include all pertinent facts, behaviors, comments, gestures, markings, clothing, or other distingishing characteristics) Bias Based On: (check all that apply): Disability Gender Gender Identity Nationality Race/Ethnicity Religion Sexual Orientation Unknown Other Offensive Materials Other If Other, please specify. If physically injured, please explain. What Department/Agencies will or have you contacted regarding this incident (check all that apply)? Academic Department/Dean Office of Multicultural Affairs Athletic Department Office of Off-Campus Student Services Counseling Center Office of Residence Life Dean of Students Office Office of the Senior Vice President for Student Affairs Department of Public Safety Slutzker Center for International Services Fix It Hot Line Student Employment Office Hendricks Chapel Student Legal Services LGBT Resource Center Syracuse Police Department None Team Against Bias (TAB) Office of Greek Life & Experiential Learning University R.A.P.E. Center Office of Human Resources Other (please specify below) Office of Judicial Affairs If Other, please explain. Contact Information: Contact information is optional and only necessary if you would like follow-up/feedback on the status and/or resolution of your report. Please fill in the relevant boxes below. Please note that you will only be contacted if you choose the YES selection in the "Contact Me" text box. Contact Me: No Yes Last Name First Name Campus Phone Other Phone E-Mail Other Can anyone else be contacted if you prefer not to be contacted? If so, please enter contact information below: Addtional information and/or comments, if any:
Your confidentiality and trust is very important to us! Everything submitted in this form will be used for investigative purposes only.
If there was more than one offender please continue below; otherwise, click here to go to event information.
If there was a third offender please continue below; otherwise, click here to go to event information.
Contact information is optional and only necessary if you would like follow-up/feedback on the status and/or resolution of your report. Please fill in the relevant boxes below. Please note that you will only be contacted if you choose the YES selection in the "Contact Me" text box.
