CSS No Name Report Tracking Form - Staff & Faculty


This form is to be completed by staff or faculty who are quasi-confidential reporters within 24 hours following the disclosure or witnessing of sexual or gender based misconduct/violence. It is intended to convey information needed to assess the level of danger the incident represents to the college community and to track the college's response to incidents of sexual and gender based violence.

* Required Fields

Reporting Party Background Information

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*Staff/Faculty Member's Name:
*Would you like to be contacted about this report?
Yes   No

Department:
If so, please leave your contact information.
Email:
Phone Number: (xxxxxxxxxx)
Date of report:
Apr-27-2015

*Is the person disclosing the victim?
Yes   No

*Date of Disclosure:



Incident(s) Details

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*Type of incident:
If the incident(s) happened on campus, what was the location(s)?
*Date of Incident:
If the incident(s) happened off campus, what was the location(s)?
Time of the Incident:

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




Accused Demographics

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Name of
Accused
Is the
accused a:
Accused
Age:
Accused
Gender:
Accused
Race:



Description/Narrative

Details on this section

Please provide a narrative of the incident:





Campus Response/Services

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Has the person spoken with anyone else
about the incident(s)?
Yes   No   N/A


Who else has the person spoken with?
Did you refer the person to any services/support?
Yes   No   N/A
If so, what?
Has the person received any services?
Yes   No   N/A
If so, what?
Did you refer to the person to any medical services?
Yes   No   N/A
If so, what?


Did the person have any suicidal ideation?
Yes   No   N/A

Any additional information you'd like to share?





Instructions/Details to Complete Form


Reporting Party Background Information:

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Please provide information about yourself as the reporter. The victim/survivor name should not be included in this form. If you'd like to be contacted, please leave the contact information for how you'd like us to connect with you. You do not have to include your information if you don't like.

Please make sure you include your affiliation to the College.

Incident(s) Details:

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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.

Victims Demographics

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This section should not include the victim's name. If the person who disclosed is not the victim (example cases of IPV or Stalking) please include the victim/survivors information in demographics, however be sure to click "No" to the question of are you the victim. For gender please use the gender identity they identify with.

Accused Demographics

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This section should help us in understanding more about the accused. If there are multiple people being accused of violence (ex: a gang rape type incident) please fill out information about each of them.

Please include the accused(s) name is known. The question regarding "type" or who the accused are will be important for statistics and our response so please be specific. If the accused is a CSS student, mark student. If the accused is a UMD student they are technically a visitor, however please mark them as "other" and then "UMD student" as we may have the ability to partner with UMD to respond to the incident.

Description/Narrative

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Please provide a detailed description of the incident/disclosure. Try to answer:
  • What happened?
  • When it happened?
  • Where it happened?
  • Who was involved (don't use the victims name!)
  • How long it has been happening (if IPV or Stalking)

Campus Response/Services

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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: _________