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Email Address: Phone Number (optional): Send me a copy of this message
1. Your Name (optional):
2. Are you a: GMU Student GMU Faculty/Staff GMU Temporary Staff Other (Please Specify)
3. Are you a: Victim Witness Other (Please Specify)
4. May we contact you for additional information? Please note that our ability to account for incidents and to be responsive will be enhanced by your willingness to be contacted. Yes No
5. Best way to contact you: Email Phone
6. If you prefer not to be contacted, is there someone else who can be contacted for more information? Please indicate the name of the person and how to reach him/her. Please provide a short explanation of why you cannot be contacted directly and how this other person can be helpful. Name: Contact Information: Why you cannot be contacted; how this other person can be helpful
7. Information about the incident: Type of Incident: Where did this occur? When did it occur? What do you think motivated the incident? (e.g. race, sexual orientation, etc...)
8. Please describe the offender(s)'s appearance - including but not limited to - name, sex, approx height and weight, skin color, hair and eye color, facial hair descriptions, what they were wearing as far as clothing, glasses or no glasses, and other distinguishing characteristics. Was the alleged offender(s) GMU students, faculty or staff? What was the ethnic or cultural background and gender of the alleged offender(s)?
9. Please tell us everything else you know or can recall about this incident and how this occurred. If you feel comfortable please include information about who was involved. What characteristic(s) do you think were targeted (gender/race/ethnicity/national background/language/religion/sexual orientation/disability/affiliations/other). Please provide as much information as you can.
10. Please list any additional witnesses (and how we might contact them).
