The University of Washington: Health and Wellness

This form is used to track the incidents of sexual assault, relationship violence (emotional, physical or sexual abuse), stalking or sexual harassment among UW students. You may have personally experienced violence or abuse or be supporting a friend, co-worker, family member or student. This form is anonymous. If you would like to be contacted by the SARIS specialist, include your name and contact information below.

All fields are optional.

Person Reporting

I am the victim/survivor I am supporting the victim/ survivor. What is your relationship to the victim/ survivor?

Type of Incident (check all that apply)

Sexual contact (fondling, kissing, touching) without consent Rape (sexual intercourse - oral, anal, vaginal with penetration) without consent

Relationship Violence

Emotional abuse Physical abuse

Stalking (series of actions that make you feel afraid or in danger - following, repeated contacts, threats) Sexual harassment (sexual conduct that alters your school or work environment such as, requests, punishment, gestures, visual displays, teasing, comments, pressure for dates) Other:

Date or Time Frames when incident occurred

Date: Time Frames:

Where did this take place?

On Campus

Residence Hall Campus Building Other:

Off Campus

Home or Apartment Sorority Fraternity Work Other:

Were alcohol or other drugs used in the incident?

If Yes, please explain:

Victim/Survivor Information

Gender: Age: Undergraduate Graduate Student Non-Student

Perpetrator Information

Gender: Age: Number of Perpetrator(s): Unknown Undergraduate Graduate Student Non-Student

Relationship of Perpetrator to Victim

Acquaintance or Friend Roomate Partner or Spouce Stranger Family Member Faculty/Staff Other:

Describe the kind of pressure or force used by the perpetrator

Verbal pressure, manipulation Threat of physical force Used physical force Gave alcohol or drugs to cause impairment Position of Authority(boss, professor, etc.) Unknown None Other:

Have you received medical care (evidence kit, STD testing,
pregnancy testing, physical exam) as a result of this incident?

Yes. Please describe: No

Other individuals/ departments you have shared this
information with

The SARIS specialist is here to listen and support all students - men, women and transgender - by providing a confidential place to discuss sexual assault, relationship violence, stalking and related issues, learn about campus resources, and understand options. Call, email or stop by the office to make an appointment with the SARIS specialist.

HUB 113
(206) 685-4357
Fax (206) 221-2533
saris@u.washington.edu

Contact Information

Would you like to be contacted by the SARIS specialist? If so, include your name and contact information here:

Incident Report Form