CalArts Anonymous Report Form

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.

Question Title

* 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.

Name of Reporter:

Email Address

Phone Number

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* 2. Today's Date

Date / Time

Date

Time

AM/PM

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* 3. Affiliation with the Incident

I am the victim/survivor of the incident

I am a third party (friend, fellow, advisor, professor, administrator).

Other (please specify)

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* 4. Type of Incident(s)

Sexual Assault

Sexual Exploitation

Sexual Harrassment

Dating/Domestic Violence

Stalking

Cyberstalking

Other (please specify)

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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.

Date of Incident: Include day/month/year, if known.

Approximate time of incident:

Victim's Name if different from reporter

Victim's Gender (Male, Female, Trans*, Gender Queer, Gender Non Conforming, etc.)

Victim's Age

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* 6. Victim's Affiliation with CalArts:

Check all that apply.

Student

Faculty

Administrator

Staff

None

Alumni

Other (please specify)

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* 7. Is there ongoing abuse?

Yes

Unknown

Other (please specify)

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

Yes

Unknown

Other (please specify)

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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.

Student

Faculty

Administrator

Staff

None

Alumni

Other (please specify)

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

Acquaintance/Friend

Intimate Partner

Former Intimate Partner

Spouse

Employer

Employee

Stranger

Unknown

Other (please specify)

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* 14. Location of Incident

On-Campus

Off-Campus

Outdoors

Residence Hall

Academic Building

Studio

Unknown

Other (please specify)

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

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

Yes

Unknown

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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.

Yes

Not now, I'll contact the Student Advocate when I am ready

Other (please specify)

Question Title

* 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.

Question Title

* 2. Today's Date

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* 3. Affiliation with the Incident

Question Title

* 4. Type of Incident(s)

Question Title

* 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.

Question Title

* 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?

Question Title

* 16. Optional: Brief Description of the Incident:

Question Title

* 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.

* 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.

* 6. Victim's Affiliation with CalArts:

Check all that apply.

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

* 12. Alleged Perpetrator's Affiliation with CalArts:

Check all that apply.

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

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

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

* 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.