This form may be completed by a member of the Macalester College community who has experienced or witnessed sexual assault, dating and domestic violence, stalking, or sexual harassment on campus. Unless otherwise specified, information given on this form will be used for statistical monitoring in compliance with the federal Student Right to Know and Campus Security Act only and will be kept confidential. Filing this form will not result in an investigation unless the victim chooses to make their identity known to an appropriate college official. There is no one way that victims of sexual violence respond to or heal from the trauma, although many do find that sharing their experience with a supportive listener and/or making an official report aided in their healing. Sharing this information may be helpful to the survivor in addition to the summary data shared with relevant offices on campus being useful in developing appropriate campus responses.

If you are a survivor of sexual violence we urge you to contact the Title IX Coordinator at 651-696-6258, the Office of Student Affairs at 651-696-6220, Campus Security at 651-696-6555, or Sexual Offense Services of Ramsey County at 651-266-1000.


Information on the Assault:

Date of Assault

Time of Assault
 am     pm

Nature of Assault (check all that apply)
 Sexual contact (intentional touching of intimate parts or clothing covering intimate parts for the purpose of sexual arousal or gratification) without consent.
 Penetration (sexual intercourse, cunnilingus, fellatio, anal intercourse, any other intrusion of a body part of an object into genital or anal openings) without consent.
 Attempted penetration
 Dating/Domestic Violence
 Sexual Harassment
 Verbal pressure/arguments
 Physical force
 Presence of Weapon
 Threat of physical force or harm
 threat of harm to family or friends
 victim under 18
 threat of negative social, academic, or employment consequences
 victim asleep
 Gave victim drugs and/or alcohol
 position of authority (boss, professor, etc.)
 Other (please explain)

Location of Assault (check all that apply)
 Residence Hall
 Off campus home/apartment
 Campus building
 Parking lot/car
 Other (please describe)

Affiliation to the victim (check all that apply)
 family member
 just met

To your knowledge, was this incident reported to a police agency?
 Yes       No       Unknown

Any additional details concerning the incident that you believe we should know:

Would you like someone from the Macalester staff to follow-up with you?
 Yes    E-mail:   Phone:
 No, I want to remain anonymous