Student Affairs > sexual-misconduct

Student Sexual Misconduct Report Form

This form may be completed by a member of the Cornell College community who has experienced or witnessed sexual assault, sexual harassment, stalking and/or sexual exploitation of or by a Cornell College student. Unless otherwise specified, information given on this form will be used only for statistical monitoring, in compliance with the federal Student Right to Know and Campus Security (“Clery”) Act, and will be kept confidential. Filing this form will not automatically result in an investigation and/or complaint. Students who wish to file a complaint (pursue student conduct action) should contact the Dean of Students. Investigations and/or other action may be initiated if the safety of the Cornell campus community is at risk or in situations required by law. If you are a student who has experienced sexual misconduct we urge you to contact the Dean of Students (319-895-4234), Sexual Misconduct Liaison (319-895-4250), or Campus Safety (319-895-4299).

Information on the Incident

Date of Incident: *
Time of Incident: *
Location of Incident (check all that apply): *		Residence Hall    Off-Campus apartment/house    Classroom    Library    Other campus building or property    Other off-campus location    Other (describe below)
If "Other" for location, please describe:
Nature of Incident (check all that apply): *		Sexual contact (any contact of a sexual nature without penetration) without consent    Sexual penetration (vaginal and/or anal intercourse, cunnilingus, fellatio, and other intrusion of a body part by a foreign object) without consent    Attempted sexual penetration    Sexual harassment    Stalking    Verbal pressure/arguments    Physical force    Abduction    Presence of a weapon    Threat of physical force or harm    Victim under 18    Threat of negative social, academic or employment consequences    Victim asleep/unconscious    Voluntary drugs and/or alcohol use    Involuntary drugs and/or alcohol use    Position of authority (boss, professor, etc.)    Other (please describe below)
If "Other" for Nature of Incident, please describe:
Affiliation of Alleged Perpetrator (check all that apply):		Partner/lover    Friend/acquaintance    Roommate    Family member    Stranger    Just met    Professor    Advisor    Supervisor    Colleague/co-worker    Staff    Student    Unknown
Person filing report:		Self (victim)    First-hand witness    Other
Affiliation of person filing report:		Cornell student    Cornell faculty/staff (including RAs)    Other
Name, if you are faculty/staff:
To your knowledge, was this incident reported to a police agency?:		Yes    No    Unknown
The Sexual Misconduct Liaison is a Cornell staff member who can provide you with more information regarding campus and area resources, your legal rights and reporting options. Speaking with the Sexual Misconduct Liaison does not initiate the complaint process.
Would you like Cornell College's Sexual Misconduct Liaison to follow up with you?:		Yes    No
Would you like to initiate a formal complaint with the Dean of Students?:		Yes    No
If you answered "Yes" in either of the above please answer the following
Name:
Email:
Phone ( XXX-XXX-XXXX):
* Required Field

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