NOTE: Information included in this form is managed and goes privately to the Confidential Student Advocate at CalArts. There will not be an IP address captured with this survey. 

No further action will be taken after receiving this form unless requested.

The following form collects information on incidences of sexual assault, sexual harassment, dating/domestic violence, or stalking. Anonymous reports are used to gather information about incidences of sexual assault and violence at CalArts, and compiled data are used to inform the community about our campus climate. Information on this form is not shared with any other persons within in or outside of the institution. 

If you would like to speak with the student advocate now, please call campus safety ext. 2222 or 661-222-2702. The student advocate is on call 24/7 and can provide information, support, and resources. You do not need to disclose any identifiable information (including your name). Simply ask to speak with the student advocate.  

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* 1. *non-mandated reporters (Students, Community Members, Health and Mental Health providers)* may file this report anonymously. *Mandated (Faculty, Staff, Teaching Assistants and Resident Assistants)* reporters must identify themselves on this form.

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* 2. Today's Date

Date / Time

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* 3. Affiliation with the Incident

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* 4. Type of Incident(s)

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* 5. The following questions ask about the incident (s) that you are reporting. If any information is unknown, please leave the question blank. Please be as detailed as possible. 

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* 6. Victim's Affiliation with CalArts:

Check all that apply.

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* 7. Is there ongoing abuse?

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* 8. Is drugging of the victim suspected?
If a specific drug is suspected, please enter information in the "other" section.

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* 9. Alleged Perpetrator's Name

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* 10. Alleged Perpetrator's Gender

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* 11. Alleged Perpetrator's Age:

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* 12. Alleged Perpetrator's Affiliation with CalArts:

Check all that apply.

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* 13. Relationship of victim/survivor and alleged perpetrator? 
Check all that apply.

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* 14. Location of Incident

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* 15. Did this incident occur at a CalArts sponsored event?

Did is happen off campus, but at a CalArts event? 

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* 16. Optional: Brief Description of the Incident:

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* 17. Would you like Maria-Victoria Perez, Student Advocate, to contact you?
If so, please provide contact information in the above fields or in the Other field below.

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