Teen Dating Violence and Sexual Assault Incident Report Form: Smithfield High School

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Smithfield Public Schools does not tolerate teen dating violence or sexual assault.

TEEN DATING VIOLENCE is a pattern of behavior where one person threatens or uses physical, sexual, verbal, or emotional abuse to control his or her dating partner.

SEXUAL ASSAULT includes behaviors that are attempted or perpetrated against a victim’s will or when a victim cannot consent because of age, disability or the influence of alcohol or drugs. Sexual assault may involve actual or threatened physical force, use of weapons, coercion, intimidation, or pressure and may include:

-Intentional touching of someone in ways that are unwanted
-Voyeurism
-Exposure to exhibitionism
-Undesired exposure to pornography or
-Public display of explicit images that were taken in a private context or when the victim was unaware.

Please reach out to a school counselor or Mr. Gallivan for additional guidance and support.

Name of Person Completing this Form (Please note, anonymous reports are more difficult to investigate and may not result in a response)

Email Address of Person Completing this Form

Phone Number for Person Completing this Form

I am a: *

Student

Parent/Family Member

Other:

Name of Alleged Victim *

Grade of Alleged Victim

Date of Incident (If multiple, most recent incident)

YYYY

Approximate Time of Incident (If multiple, most recent incident)

Time

Describe the location of the incident.

Did this incident occur at school or another location?

List the name of the alleged aggressor/aggressors. If name is not known, provide any other identifiable information:

Describe the incident and situation with as much detail as possible to help the person looking into the issue.

When and where did it happen?

Were there any witnesses? If yes, who?

Any other pertinent information, including previous incidents or threats:

What sort of help would you like with this issue?

Submit

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