INTAKE REPORT OF INCIDENT(S) OF SEXUAL VIOLENCE & SEXUAL HARRASSMENT Step 1 of 3 33% PART I: INFORMATION ABOUT INDIVIDUAL(S) MAKING A REPORTFull Name* First Last Date of Birth Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Can The University send mail, related to this report, to this address? Yes No Email* Are you a Member of The University of Toronto Community (i.e., student, staff or faculty at The University of Toronto)? Yes No If Yes Student Staff Faculty Volunteer Other Please elaborateHow would you like to be contacted? Email Phone Please enter your phone number here:If phone, may a message be left? Yes No I have: (check all that apply) Experienced an incident(s) of sexual violence Witnessed an incident(s) of sexual violence Received a disclosure of sexual violence PART II: INFORMATION ABOUT THE RESPONDENTFull Name First Last Faculty or Department:Student Number / Employee Number:Is the Respondent a Member of the University of Toronto Community (i.e., student, staff or faculty at The University of Toronto)? Yes No I don't Know If Yes, what is that Respondent's role at The University of Toronto? (check all that apply) (i.e., student, staff or faculty) at University of Toronto? Student Staff Faculty Volunteer I don't Know Other Please elaborate PART III: INFORMATION ABOUT THE INCIDENT(S) OF SEXUAL VIOLENCE BEING REPORTEDType of Sexual Violence you are reporting: (please check all that apply) It is recognized that it may be difficult to label an experience of sexual violence. You are not required to label your experience in order to file a report. Sexual Assault Sexual Harassment Stalking Indecent Exposure Voyeurism Cyber Harassment Sexual Exploitation Gender-based Harassment I don't know Other Please elaborateDate of Initial Incident Summary of Incident: In your own words, please summarize what happened. Dates, times and place(s) of incidents may be helpful. However, you are encouraged to share only the amount of information that you are comfortable providing.*Date of Next Incident Summary of Incident: In your own words, please summarize what happened. Dates, times and place(s) of incidents may be helpful. However, you are encouraged to share only the amount of information that you are comfortable providing.Witnesses: Please list names and contact information of any witnesses that may be involved. Please note that the names listed may be contacted to request their participation in a formal process that may be initiated under Policy on Sexual Violence and Sexual Harassment. Witnesses:NameEmailPhone Have you contacted any Academic or Administrative Leaders (i.e., Deans, Chairs, Managers, Supervisors, etc.) about this incident? If so, please list who you have contacted. Please note that the names listed may be contacted to gather more information or to request their participation in a formal process that may be initiated under Policy on Sexual Violence and Sexual Harassment. NameContact InformationRole at The University Other information: Is there any other information you would like to provide?Signature or Name of Individual Filing ReportDate CommentsThis field is for validation purposes and should be left unchanged.