Sexual Violence Reporting Form

Please use this form only if you have experienced an incident of sexual violence and you wish to report it to Western.   A report initiates a formal process under Western’s Policy on Sexual Violence.  

If you do not wish to initiate a formal process or you haven’t decided, you may contact Western’s Sexual Violence Prevention and Education Coordinator (if you are a student) or Equity & Human Rights Services (if you are an employee) to learn more about your options, including how to access supports, services or accommodations.

This form is not to be used in an emergency or during an event(s) presenting an immediate threat to the health or safety of yourself or any campus member.  If you require emergency assistance, please call 911.  Students living in residence may also contact their front desk in an emergency (to be connected with the Residence Manager on-call).   

Once you submit this form, it will be received and reviewed by the Judicial Affairs Office (for matters involving students) or Equity & Human Rights Services (for matters involving employees) within 72 hours. You will be contacted directly by one of these offices to confirm the form’s information and to confirm the next steps.   

The fields on this form are not mandatory.  However, please be aware that that if you do not provide a method for us to contact you (at question 4), Western’s ability to respond and/or take further action will be limited.

Information provided on this form is administered and retained in accordance with Western’s Policy on Sexual Violence.  For more information about Western’s procedures on Sexual Violence, please review the Policy on Sexual Violence.

Information about Individual Making the Report (i.e., Victim/Survivor, Witness)



 Student
 Staff
 Faculty
 Volunteer
 Alumni

3. Type of Sexual Violence you are reporting: (please check all that apply)
 Sexual Assault
 Sexual Harassment
 Stalking
 Indecent Exposure
 Voyeurism
 Cyber Harassment
 Sexual Exploitation

 I don't know. We recognize that it may be difficult to label an experience of sexual violence. You are not required to label your experience in order to file a report.

4. How would you like to be contacted? Phone and/or email?
Please note that unless you provide a contact method, we cannot follow up.



If phone, may a message be left? Yes No



Information about Individual Alleged to have breached the Sexual Violence Policy (i.e., Respondent)


 Yes 
 No
I don't know


 Student
 Staff
 Faculty
 Volunteer
 Alumni


Other Information

Is there any other information you would like to provide?  This is not to be used to describe the incident(s).  A maximum of 300 characters is permitted.