Survivor: Sexual Violence Disclosure Form

Please don't fill out this input box.

Survivor's Name

Survivor's Email

Survivor's Phone Number

Campus Status of Survivor Please Select Student Faculty Staff

Type(s) of Sexual Violence Experienced by the Survivor

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

Other

If you selected "other", please explain.

Additional Information

Name of Person Accused

Campus Status of Person Accused

Student

Faculty

Staff

Brescia

Huron

King's

Western

Other

Check all that apply.

If you selected "other", please specify

Email of Person Accused

Phone Number 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.

Date of Incident

Time of Incident Include a.m. or p.m.

Location of Incident

Incident Description

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 accommodations

Accessed campus resources

Accessed off-campus / community resources

Completed a Campus Police Report to keep on file

Consulted with Campus Police in an informational meeting about their reporting options

None yet

Don't know...

Other

Check all that apply.

If you selected "other", please specify

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

Check all that apply.

If you selected "other", please specify

Please provide any other information that may be helpful

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