Date Reported

Type of Incident

Date of Incident

Location of Incident (check one)
On campus
campus residences
off-campus
Salzburg Program
Other:

Victim (check one)
student
non-student
employee
visitor
contractor
Other

Were the police notified? YES NO

Were you injured? YES NO

Was this incident motivated by the victim’s race, sexual orientation, ethnicity, gender, religion, or disability? YES NO

Did you know the suspect? YES NO

Was the suspect a student or employee of the university? YES NO

Would you be willing to talk to Public Safety about this incident if you knew that your name would remain anonymous? YES NO

Brief description of the incident