Please don't fill out this input box. Today's Date*Please enter today's date. Reporter's Name (optional)Please enter the name of the person who reported the incident. I (the reporter) would like to be contacted by someone from the following UNT System Offices (please check all that apply): Please contact Equal Opportunity Compliance Officer Title IX Coordinator I don't want to be contacted Phone Number Email Address INCIDENT DETAILS Nature of Report* Please Select Sexual Assault Dating Violence Stalking Date and Time of Incident* Location of Incident Please Select Work Place UNT System Building Car or Vehicle Outdoors Parking Lot Was incident previously reported to a campus department or external agency?* Please Select Yes No Unknown VICTIM(S) Victim(s) Name(s) (optional) Gender of Victim* Please Select Male Female Has the victim received any additional resources (i.e. counseling or medical attention)? Victim's Affiliation to UNT System* Please Select Staff Not Affiliated Other ASSAILANT(S) Name of Assailant(s) Gender of Assailant(s) Please Select Male Multiple Males Female Multiple Females Male and Female Unknown Assailant's Relationship to Victim Please Select Partner, Grlfriend, or Boyfriend Friend Ex-Partner, Ex-Girlfriend, or Ex-Boyfriend Faculty Teaching Assistant Staff Member Work Supervisor Colleague or Co-worker Acquaintance Stranger Other Assailant's Relationship to UNT System Please Select Student Faculty Staff Not Affiliated Unknown Other USE OF ALCOHOL OR DRUGS Assailant's Use of Alcohol or Drgs Please Select Used alcohol Used drugs other than alcohol Unknown whether drugs or alcohol were used Was Victim given alcohol and/or drugs without consent or knowledge? Please Select Yes alcohol Yes drugs Yes alcohol and drugs No Unknown If alcohol and/or drugs were involved, did the victim feel pressure to consume or use? Please Select Yes NoForm UUID Site Name Submit Clear