SEXUAL MISCONDUCT REPORT FORM

SEXUAL MISCONDUCT INCLUDES: ASSAULT, RAPE, AND ALL OTHER FORMS OF SEXUAL VIOLENCE

CLICK FOR MORE INFORMATION: HOW TO USE THIS FORM

Cayuga Community College is committed to the safety and well-being of all students, faculty and staff. The institution’s goal is providing an optimal environment for learning, exploring and making lasting, positive connections within the campus-community. Fostering this productive atmosphere requires that all members remain vigilant in safeguarding policies, statutes and laws protecting the rights of each member to pursue an educational experience free of harassment and risk of personal harm.

This form serves as a means of supporting victims/survivors experiencing any form of sexual misconduct as well as properly documenting and potentially pursuing offenders deviating from expectations set forth by the college.

Please note that, as a member of the Cayuga Community College community, you have an obligation to uphold the highest standards as a student, faculty and staff member of this institution. As such, your decision to engage in completing this form is a testament to your commitment to these standards and most importantly, in advocating for those who may not possess the immediate capacity to advocate for themselves.

Please complete the following question to the best of your ability. Take care in explaining to the victim/ survivor that this information serves a very important purpose and is legally required through Title IX and mandates set forth through State and Federal governments. However, underscore the following points:

  • Collecting this information does not mandate disclosure of the victim/survivor’s identity and evert effort to impart this important fact and safeguard confidentiality must be made.
  • This form is not a police report and although this information may be supplied to law enforcement at the Title IX officer’s discretion, the victim/survivor alone is the only one who may decide if he or she wishes to pursue criminal charges
  • Although this is not a police report, every effort should be made to inform the victim of his or her rights and resources, including reporting the incident to the authorities and emphasizing that a report does not have to include pressing charges.

THIS INFORMATION WILL BE SENT TO:

Pamela Heleen
Title IX Coordinator
Executive Assistant to the President
Cayuga Community College
197 Franklin Street, Auburn NY

Office: M236
Phone: 315-294-8508
E-mail: pamela.heleen@cayuga-cc.edu

1. Campus information
Required Field
2. Are you reporting an incident/assault that happened to you or an incident/assault discussed with you?
3. Person making this report
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Required Field
Required Field
4. When did the Victim/Survivor first discuss the incident/assault with you?
5. Did incident occur while the Victim/Survivor was enrolled at Cayuga Community College?
6. Victim/Survivor information
7. Victim/Survivor’s residential status
8. Location of incident/assault
9. Approximate time and location (building, street, etc.) of incident
10. Was the incident/assault associated with an organized event (campus sponsored)?
11. Describe the incident/assault
12. Describe the pressure or force used by the assailant(s)
13. Was a weapon used in the incident/assault?
14. Assailant(s) information
15. Status of assailant(s)
16. Describe the nature of the relationship of the assailant(s) to the Victim/Survivor prior to incident
17. Other departments at Cayuga Community College the Victim/Survivor has reported this incident/assault to or discussed it with
18. Is the victim receiving counseling or other services in relation to the incident?
19. Other individuals at Cayuga Community College that the Victim/Survivor has talked with about this incident
20. Did you refer the Victim/Survivor to other resources on or off campus?
21. Does the Victim/Survivor want to be contacted by a Campus Counselor or Student Victim Advocate?
Required Field
22. Name of Victim/Survivor (only if they wish to disclose it)
Required Field
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23. How to contact Victim/Survivor (only if they wish contact)
24. Additional Comments