Instructions: This form is intended to track incidents of sexual misconduct on the Whitman campus and to determine which resources are being accessed. Please submit this form as soon as it is completed.

Information being reported was obtained from person involved in incident or heard from others

Person's age: Person's academic year: Person's gender:

Date of incident: Time of incident: a.m. p.m.
Occurred on campus? Selct Yes or No Yes No

Where did the incident occur? (name of building, street, etc.)

Describe incident:

sexual contact (fondling, kissing, petting but not penetration) without consent
attempted intercourse without consent (penetration did not occur)
intercourse (oral, anal, or vaginal penetration by penis or other object) without consent
other, describe:

Was the absence of consent due to impairment by:
a) alcohol? Yes No Do not know
b) other drugs? Yes No Do not know
c) being asleep? Yes No Do not know

Describe the kind of pressure or force used:

none
verbal pressure or arguments
position of authority (boss, teacher, supervisor, etc.)
threat of physical force (threatened to hit, hold, or otherwise injure)
actual use of physical force (hit, held down, twisted arm, etc.)
gave alcohol or drugs to cause impairment
do not know

Describe nature of relationship prior to the incident:

Other contact points or departments the victim/survivor reported this incident to:

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