Campus Safety Notice You must have JavaScript enabled to use this form. Complainant Information Entering personal contact information is completely optional. We invite you to submit this form anonymously, however if you would like to be contacted regarding your submission be sure to include the necessary contact information. Name of Complainant/Witness Phone Email Please contact me via - None -PhoneEmailBoth Incident Information Approximate Date and Time of Incident Approximate Date and Time of Incident: Date Approximate Date and Time of Incident: Time Location of Incident Type of Incident Sexual Assault Damage or Destruction of Property Physical Harassment or Assault Verbal Harassment Phone Harassment Written Harassment Email/Online Harassment Graffiti Intimidation Vandalism Other Nature of Incident Age Gender Religion Race Disability Marital Status Sexual Orientation National Origin Ethnicity Gender Identity or Presentation Culture Veteran Status Ex-Offender Status Other… Enter other… What bias do you feel was the target of the incident? Please select all categories that apply. Detailed Description of Incident Please include all pertinent facts, behaviors, comments, gestures, markings, clothing, or distinguishing characteristics. Was anyone physically injured? - Select -YesNo Please explain the injuries mentioned above Were there other witnesses? - Select -YesNoUnknown Names of other witnesses Optional Affiliation with Doane Affiliation with Doane - Select -StudentFacultyStaffVisitorOther… Enter other… Additional Information How did you hear about the ART system? How did you hear about the ART system? - None -FriendsStaffFacultyRA/Residence LifeOther… Enter other…
