Incident Reporting Form
Were you a witness or a victim?
Please Choose
Witness
Victim
Your Gender:
Please Choose
Female
Male
Race/Ethnicity:
Your Age:
Status:
Please Choose
Student
Faculty
Staff
Other
Do you live on or off campus?:
Please Choose
On Campus
Off Campus
Date of Incident:
Time of Incident:
Location of Incident:
Number of Perpetrators:
Describe the Incident:
Would you like to be contacted by the Office of Student Life?:
Please Choose
Yes
No
Personal Contact Info
Note: If you are under 18 years of age and do not want to make an official police report, do not include your name on this form.
(Optional) if you woul like to be contacted, please provide the information below.
Name:
Phone:
Email:
Perpetrator Information
Perpetrator Gender:
Please Choose
Female
Male
Perpetrator Race:
Perpetrator Age:
Perpetrator Status:
Please Choose
Student
Faculty
Staff
Other
If Student, Classroom Status:
Please Choose
Freshman
Sophomore
Junior
Senior
Years attending UW-Platteville:
If other, please describe:
Describe the nature of your relationship with the perpetrator prior to the incident:
Please include additional information if there is more than one perpetrator: