Reporter's Information (the reporter and survivor can be different people)


Today's Date


Reporter's Name (optional)


Reporter's Relationship to Survivor


Reporter's Gender

Check this box if you are reporting a sexual assault, but you are not the survivor.

I (the person making this report) would like to be contacted by someone from the following MacMurray College offices (please check as many as apply):
Dean of Student Life
Title IX Office
Health Services

Please contact me using the following phone number and/or email address.


Phone


Email


Survivor's Information


Survivor's Name (optional)


Survivor's Gender


Survivor's Age

Survivor's affiliation to MacMurray College:
Student
Faculty
Staff
Not affiliated
Other:


Offender(s)' Information

Note: If an offender(s)' name or group affiliation is listed, the institution may take action with the offender(s) or group.


Number of Offender(s)


Names of Offender(s) (optional)

Gender of offender(s):
Male
Female
Multiple Males
Multiple Females
Males and Females
Unknown

Offender(s)' affiliation to MacMurray College:
Student
Faculty
Staff
Not Affiliated
Unknown
Other:

Offender(s)' relationship to survivor:
Partner, girlfriend, or boyfriend
Friend
Ex-partner, girlfriend, or boyfriend
Partner, girlfriend, or boyfriend
Faculty, teaching assistants
Staff member
Work supervisor
Colleague or co-worker
Acquaintance
Stranger
Other:

Offender(s)' use of alcohol and other drugs (check all that apply):
Used alcohol
Used drugs other than alcohol
Unknown whether alcohol or drugs were used


Assault Information


Date of Assault


Time of Assault

Location of assault (check all that apply):
Survivor's dorm room
Offender's dorm room
Workplace
Campus building:
Car/vehicle
Residence hall
Off-campus apartment/house
Outdoors
Parking lot
Other:

Reported assault (check all that apply):

Attempted sexual assault/misconduct
Completed sexual assault/misconduct ( Oral Vaginal Anal)

Was the survivor given alcohol and/or other drugs without consent or knowledge?
Yes, alcohol
Yes, drugs
No
Unknown

If yes, did the survivor feel pressure to consume or use?
Yes
No


Other Reports

To your knowledge, has anyone previously reported this incident to another department or office (Student Life, Title IX, Security, Health Services, Residential Life, etc.) or external agency (hospital, police, etc.)?
Yes
No
Unknown


Description of the Incident