Confidential Report Form


This form is to be completed by staff who are confidential reporters (CSS Counselors, CSS Health Service, CSS Student Support Services) within 24 hours following the disclosure of sexual or gender based misconduct. It is intended to accurately reflect statistics of sexual violence while keeping anonymity and confidential resource for the victim/survivor.

* Required Fields

Incident(s) Details

Details on this section

Date of Report:
May-03-2015
Date of Disclosure:

Date of Incident(s):
Location of Incident(s)

*Type of incident:
If there is any more information about the date or time of
the incident please include here:


Victim's
Age:
Victim's
Gender:
Victim's
Race:

Accused
Age:
Accused
Gender:
Accused
Race:




Campus Response/Services

Details on this section

Did you provide the student any resources/services/referrals, if so what/whom/where?






Instructions:


Incident(s) Details:

Return to section ^
This section allows the College to keep up to date and accurate statistical information about the incident(s). This information will help the College in completing our Annual Security Report (via Clery) and the Campus Daily Crime Log.

For cases of IPV or Stalking which are patterned crimes, please include the dates and location the student discloses. If the student doesn't provide exact dates but says "the last three months" please share that so we know how long these incidents have been occuring.

Please be as specific as possible when referring to location. For example if it happened on campus in Somers Lounge, please say Somers Lounge. If the incidents were in a car on College Street, please say in an automobile on College Street.

Campus Response/Services

Return to section ^
The answers to this question will help us better track the campus response. It also may allow us to ensure we are not double counting statistics.

If the student has spoken to someone(staff or faculty) on campus, please provide a name (if possible). If a student has spoken or received services from an organization, share that as well.

Also please mark if you referred them to speak to someone or an organization.

Some options for Services/Support could be:
  • Counselor
  • GEVA Team member
  • Residential Advisor/Residential Director
  • Dean of Students
  • Community Advocate: PA VSA, Safe Haven, Safe Haven Resource Center
  • Legal Advocacy
  • CSS Health Services
  • Local Hospital: St. Lukes a/o St. Mary
  • Academic Advisor
  • Campus Security
  • Duluth Police
  • Other: _________