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Division of Student Affairs

Sexual Misconduct and Relationship Violence Anonymous Report Form

 

Vice President for Student Affairs
203 Werner University Center
503-838-8221

 

Student Health and Counseling Center
503-838-8313

 

Information on the Survivor
  (optional for survivor)
Note: Faculty and staff must report name of survivor
   
*required
 
Providing date of birth is a confidential means to differentiate incidents and reduce duplicate statistics.


(check all that apply):


(check all that apply):

(check all that apply):

 

 

Information on the Assault

If a survivor wishes for the assault to be recorded in university statistics, this section must be completed in full. All mandatory reporters are required to complete this section as well.

 

     

 


(check all that apply):

 

 

(check all that apply):

 

 


 

Note: An incident does not have to involve coercion or force to be considered a student conduct violation. Reporting drug or alcohol use here will not result in any sanctions for the survivor. For more information, contact the Office of Student Conduct.

 


 

Follow-Up

 

 


 

 


 

 

Information about the Person Completing this Form

 Name required

 


 

 

Contact

Office of the Vice President for Student Affairs 503-838-8221 | or e-mail: studentaffairs@wou.edu

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