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University Democrats Incident Reporting Form
The following form can be used to report incidents involving members of the University Democrats at UVA. There is no time limit on reporting incidents, and reports can be made about past events. The form is anonymous by default, and no personal information is collected.

If the incident you are reporting is an emergency, please call 911.

If you have any questions about the form, or wish to report an incident in person, please reach out to one of the following designated contacts on the Executive Board of the Organization. They can help you through the process of reporting or direct you to relevant resources.

Andrew Prince (Male contact): acp8ww@virginia.edu / (703) 380-1227
Kiera Goddu (Female contact): kag5n@virginia.edu / (804) 396-0289
Jackson Samples (LGBTQ+ contact): jds2wd@virginia.edu / (703) 628-4283

We encourage you to take advantage of the following support resources:

Title IX Information: https://www2.ed.gov/about/offices/list/ocr/docs/tix_dis.html
UVA Title IX Office & "Just Report It!" system: https://eocr.virginia.edu/title-ix
National Sexual Assault Survivor Hotline: 1-800-656-4673
National LGBT Hotline: 1-888-843-4564

General Information
What is your affiliation to UVA? *
Please indicate the type of incident which you are reporting *
Required
Who is reporting this incident? *
If you are the victim and wish to attach your name to the report, do so below. If you wish to remain anonymous, leave this question blank.
Your answer
If you are reporting on the behalf of another individual and wish to attach your name to the report, do so below. If you wish to remain anonymous, leave this question blank.
Your answer
If you have chosen to attach your name to the report, and wish to have a member of the Executive Board follow up with you regarding it, please write your email address below. If you wish to remain anonymous, leave this question blank.
Your answer
Respondent
The respondent is the individual who committed the reported conduct.
Do you know the identity of the respondent? *
If you know the name of the respondent and wish to report it, do so here.
Your answer
If you do not know the respondent's name but have other identifying information, please list it here.
Your answer
Date and Location of Incident
Do you know the date of the incident? *
Please list the date or dates, if known. If no date is known, please list approximate dates. *
Your answer
Do you know the location of the incident? *
Please list the location(s), if known. If no location is known, please list as much information as possible. *
Your answer
Incident
Please provide a description of the incident or conduct you are reporting using specific, concise, and descriptive language. If applicable, please also indicate your desired outcome. *
Your answer
Additional Comments
If necessary, please provide any additional comments.
Your answer
Acknowledgements
I acknowledge that my confidentiality will be respected. If I have chosen to remain anonymous in this report, no effort will be made to identify me. *
If I have chosen to identify myself in the above report, a member of the Executive Board may reach out to me to follow up on the incident. *
If the incident I described potentially constitutes a violation of Title IX, I would like a member of the Executive Board to assist me in filing an official Title IX report. *
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