Student Gender Violence Incident Notification Form:

If you are a faculty or staff remember submitting a report about an incident brought to your attention, use the Faculty/Staff Incident Notification Form.

The purpose of this form is to notify Lehigh University that an incident of gender violence has occurred. This form should NOT be used in an emergency. If this is an emergency and you need immediate assistance, please call the Lehigh University Police Department at (610) 758-4200. You should report incidents of harassment by using Lehigh's harassment policy protocol, rather than this form.

If you would prefer to talk to someone, you can also notify the University of a Gender Violence Incident 24 hours a day, 7 days a week by calling the Lehigh University Police Department (610.758.4200) or an Advocate (610.758.4763). In addition, you can obtain information about gender violence resources 24 hours a day, 7 days a week during the fall and spring semesters by calling the Break the Silence gender violence peer hotline (610.974.HOPE).

The Assistant Director of the Women's Center, the Lehigh University Police Department, and other University employees who have a specific "need to know" will review and record the information that you submit about an Incident. The University will respond to the information in a way that takes into account your wishes, as well as any legal requirements or University obligations. Please understand that under certain circumstances, the University may have an obligation to act upon the information you provide even if you request that the University take no action beyond recording the incident. For example, the University will need to investigate situations that may threaten the safety of anyone mentioned in this form or the Lehigh University community. Alternatively, please understand that if you do not complete the form fully, the University may be limited in its ability to take action, even if you would like us to do so.

If you have questions regarding the use of this form, feel free to contact an Advocate (610.758.4763) to discuss your options. Any misuse of this form is a violation of Lehigh University's Code of Conduct. The University will investigate any possible misuse of this form 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.

Involved Parties

Survivor(s') Name(s) (if not anonymous):

Credit Standing:

Credit Standing:

Credit Standing:


Incident Information

Incident Type(s):



Location:




Perpetrator Relationship:

Alcohol Use:

Medical Attention:

Police Report:

Incident Type

Intimate Partner Violence Behavior(s) (if any):

Stalking Behavior(s): (if any)







^ Please understand that under certain circumstances, the University may have an obligation to act upon the information you provide even if you request that the University take no action beyond recording the incident. For example, the University will need to investigate situations that may threaten the safety of anyone mentioned in this form or the Lehigh University community. Alternatively, please understand that if you do not complete the form fully, the University may be limited in its ability to take action, even if you would like us to do so.


Resources http://www.lehigh.edu/~inwnc/gethelp.html

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