Sexual Assault/Violence Report

Comments

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Your Information

Please check*

 I am the person who experienced the incident.
I am reporting an incident on behalf of someone else.

Would you like to submit this report anonymously?

Yes
No

Anonymous reports may limit the College's ability to investigate or respond to the incident. However, they help the College understand trends and improve prevention efforts.

Your Name

First Last

Your Email Address

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NOTE: A confirmation email will be sent to this email address when this form is completed.

Phone Number

This phone number will be used to follow up with you within 72 hours. We may leave you a voicemail.

Your Relationship to the College

Student
Staff
Other

Incident Information

Date of Incident*

Time of Incident ( if known)*

:

Nature Of Sexual Assault/ Violence. Please check all that apply.

Sexual Assault
Sexual Harassment
Stalking
Indecent Exposure
Voyeurism
Sexual Exploitation
Prefer not to disclose

Other than those described above. Please specify.

Information About the Respondent(s)

Information about the respondent(s) or person(s) alleged to have engaged in the behaviour.

Name of Respondent(s) (if known).

What is the respondent's relationship to the person who experienced the incident? (Select all that apply)*

Current partner
Former partner
Friend
College employee
Acquaintance
Stranger

Respondent's relationship to Algonquin College*

Learner
Employee
Visitor
Unknown

Location of Incident. Please check all that apply.

On Algonquin College Campus
In Algonquin College Residence
Off campus at a college sanctioned activity
Off campus and unrelated to the college
Vehicle

Alcohol and/or drugs involved?*

Yes, alcohol
Yes, drugs
No
Unknown

Incident Description - Please describe what happened, including the sequence of events and any witnesses.*

Have the Police been contacted?*

Yes
No
I would like assistance contacting the police.

If yes, enter police force and file number below:

Has this incident affected your education, employment, or ability to participate in College activities? *

Yes
No

If yes, please describe:

If you are a student you are strongly encouraged to talk to Counselling Services, Health Services, or your program Chair to discuss options for accommodation and/or support. For more information regarding the process please contact Security Services at 613-727-4723 ext. 5010. If you are staff or an employee you are strongly encouraged to speak with your Supervisor or Human Resources.

Risk Management