This form should NOT be used in an emergency. If you need immediate assistance, call the Lehigh University Police Department at (610) 758-4200.
Reports can also be made 24 hours a day, 7 days a week during the fall and spring semesters via the Break the Silence sexual violence peer hotline (610-974-HOPE).
Information about any reported incidents will be recorded and seen by the Assistant Director of the Women’s Center and University staff who have a “need to know.” Please understand that even if you request that Lehigh University take no action beyond recording this incident, Lehigh University may, depending upon the circumstances, respond institutionally to situations that may threaten the safety of anyone mentioned in this report or the Lehigh University community.
Any misuse of this form is a violation of Lehigh University’s Code of Conduct. The Assistant Dean of Student Conduct will investigate any possible misuse and take disciplinary action as appropriate.
Directions: You are encouraged to fill out the entire form, though you may skip any portion of the form you do not wish to complete. If you do not have knowledge about some of the information requested on the form, skip that portion.
You are: Female Male
Credit Standing: Undergraduate Graduate
Survivor/Reporting Party's Name (if not anonymous):
Perpetrator(s) Name(s) (if not anonymous):
Witness(es), if any:
Location: On-Campus (residence hall, fraternity, sorority) On-Campus (Non-Residential) Off-Campus (Lehigh Property) Off-Campus (Bethlehem) Off-Campus (not in Bethlehem)
Perpetrator: Male Female Acquaintance Family Member Lehigh Student Stranger
Alcohol Use: All Parties Survivor Only Perpetrator Only No One
Medical Attention: Yes / Rape Evidence Exam Yes / No Rape Evidence Exam Not Yet No
Police Report: Yes No Not Yet
Location: On-Campus Off-Campus
Perpetrator: Male Female
Behavior(s): Verbal Abuse Physical Abuse Both
Perpetrator: Male Female Acquaintance Lehigh Student Stranger
Behavior(s): Phone Calls Emails/IM Letters/Gifts Following / In Person Contact Threat(s) of Violence
Behavior(s): Verbal Sexual Harassment Physical Sexual Harassment Assault, Threats, Property Damage Biased Comments
Police Report: Yes No Not yet
Please describe the incident(s) in as much detail as you are willing to provide:
How would you like Lehigh to follow up on this report? Contact the Survivor Contact the Perpetrator Record the incident only Other, please specify:
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