This form is to be used only for incidents toward student(s) at UCSD. All questions are OPTIONAL and all information provided will be kept confidential to the extent possible under the law and UCSD policies.

I. Incident information
Date of incident (mm/dd/yyyy)
Time am pm
Date of report (mm/dd/yyyy)

Please provide information about the location of the incident, if possible:
On Campus Off Campus
Location (specify)

Type of Incident (check all that apply):
Verbal Assault Physical Assault Threat of Physical Assault
Written Slur Fear for Safety Phone Harassment
Sexual Harassment Property Damage Pursuit/ Chase
Threat of "outing" E-mail/ Internet Messages Stalking
Public indecency/ Exposing one's genitals Sexual Assault
Other (specify)

Please provide a detailed description of the incident including information about witnesses (How many? Who were they?):


II. Perpetrator Information
Perpetrator: person intimidating, harassing, and/or discriminating was
Name(s): Phone(s):

Gender: Male Female Unknown
Other (please specify)

UCSD Affiliation:
UCSD student UCSD faculty member UCSD staff member
Other (please specify)


Other Facts about the Perpetrator: