Today's DatedatetimeThis field is required.Please enter today's date.Reporter's Name (optional)falsePlease 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 contactfalseEqual Opportunity Compliance OfficerTitle IX CoordinatorI don't want to be contactedPhone NumberfalseEmail Addressfalse<strong>INCIDENT DETAILS<br /></strong>Nature of ReportThis field is required.Sexual AssaultDating ViolenceStalkingDate and Time of IncidentdatetimeThis field is required.Location of IncidentfalseWork PlaceUNT System BuildingCar or VehicleOutdoorsParking LotWas incident previously reported to a campus department or external agency?This field is required.YesNoUnknown<strong>VICTIM(S)</strong>Victim(s) Name(s) (optional)falseGender of VictimThis field is required.MaleFemaleHas the victim received any additional resources (i.e. counseling or medical attention)?falseVictim's Affiliation to UNT SystemThis field is required.StaffNot AffiliatedOther<strong>ASSAILANT(S)</strong>Name of Assailant(s)falseGender of Assailant(s)falseMaleMultiple MalesFemaleMultiple FemalesMale and FemaleUnknownAssailant's Relationship to VictimfalsePartner, Grlfriend, or BoyfriendFriendEx-Partner, Ex-Girlfriend, or Ex-BoyfriendFacultyTeaching AssistantStaff MemberWork SupervisorColleague or Co-workerAcquaintanceStrangerOtherAssailant's Relationship to UNT SystemfalseStudentFacultyStaffNot AffiliatedUnknownOther<strong>USE OF ALCOHOL OR DRUGS</strong>Assailant's Use of Alcohol or DrgsfalseUsed alcoholUsed drugs other than alcoholUnknown whether drugs or alcohol were usedWas Victim given alcohol and/or drugs without consent or knowledge?falseYes alcoholYes drugsYes alcohol and drugsNoUnknownIf alcohol and/or drugs were involved, did the victim feel pressure to consume or use?falseYesNo

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