For Faculty/Staff: Gender Violence Incident Notification Form (i.e sexual assault, intimate partner violence, stalking)

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 you need immediate assistance, 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.

Incident notifications can also be made 24 hours a day, 7 days a week via the Lehigh University Police Department at (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 the Assistant Director of the Women's Center (610.758.5808) to discuss your options.

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. Some fields, however, are required (denoted by *).

Initial Contact

Student:

How was student affiliated with incident:

Credit Standing:

Incident Information

Incident Type(s):


Location:





Perpetrator: (Check all that apply)








Alcohol Use:

Medical Attention:

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

Stalking Behavior(s): (if any)





Police Report:

Resources Given: (Check all that apply)







Result of Notification





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