Sexual Violence Anonymous Reporting Form
This form should be used by members of the Blake Austin College community who have experienced or have been witness to sexual violence (sexual assault, rape or sexual battery). The information will be used to identify and address troubling trends. If a perpetrator is named, a member of the Title IX Team will meet with that person to share that the person was named in an anonymous report, review the Sexual Misconduct Policy, and inform the person that if the allegations are true, the behavior needs to cease immediately. Information shared in this form alone will not result in anyone going through the conduct process.
In compliance with the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act (Clery Act) (20 U.S.C. section 1092), information submitted via this form reflecting a reportable crime, as defined by the Clery Act, will be included in the Campus Safety Daily Crime Log. No names are included in the Daily Crime Log.
If you are a survivor of sexual violence, there is HELP AVAILABLE:
Emergencies: 911
Rape/Crisis Hotline:
24 hours a day, confidential reporting and assistance
(800) 656-HOPE(4673)
2000 L Street North West Suite 406, Washington DC 20036 OR

SafeQuest Solano
866-4UR-SAFE (866) 487-7233
If you would like to pursue conduct action, contact:
Mandy Dass, Director of Academics
Title IX Officer - (707) 455-0557

Date of assault MM/DD/YEAR or leave blank if you do not know
MM
/
DD
/
YYYY
Nature of assault
Location assault occurred
Please provide details of the incident
Your answer
Survivor Information
Survivor status
Gender of survivor
Your answer
Perpetrator Information
Perpetrator status
Gender of the perpetrator
Your answer
What is the name of the perpetrator?
Your answer
Person Reporting Information
Your answer
If you are not the survivor, how did you learn of this incident?
Submit
Never submit passwords through Google Forms.
This form was created inside of Blake Austin College. Report Abuse - Terms of Service - Additional Terms