Incident Reporting Form

(Anonymous Reporting is Optional)

Thank you for reporting. If this is of life threatening nature or immediate care/response is needed, please contact police by dialing 911 and follow up with a call to Public Safety on the University campus at (651) 631-5310.

This is a secure reporting format accessible only to the Title IX and Public Safety office on the University of Northwestern - St. Paul campus. Submissions are not continually monitored and will be typically reviewed on the next business day. You are not required to complete the entire form in order for the incident report to be submitted; however, you must complete fields denoted with an asterisk. The University will use the information provided to address the complaint, which can include an investigation and contacting the parties involved. If the report does not contain specific information, the University’s investigation and response may be limited.

All reports may be submitted anonymously; however, if you are the victim/survivor reporting, please know that doing so may limit the University’s ability to address the matter and assist you. In addition to completing this report, the Title IX Coordinator can be reached at TitleIX@unwsp.edu or mlbuchholz@unwsp.edu.

Off-campus resources: Sexual Offense Services (St. Paul), 651-266-1000, sos@co.ramsey.mn.us, RAINN (Rape, Abuse, and Incest National Network), 800-656-HOPE (4673) (24-hour hotline), Sexual Violence Center Minneapolis, 612-871-5111 (24-hour hotline).

Select the Type of Incident or Crime:

First Name

Middle Name

Last Name

Status:

Phone Number:

E-mail:

Physical Address:

Approximate Date of Incident:

Approximate Time of Incident:

Hour

Minute

am/pm

Please describe other location (include address)

List of all Parties Involved:

Name

Gender:

Role

Location:

E-mail:

Name

Gender:

Role

Location:

E-mail:

Name

Gender:

Role

Location:

E-mail:

Name

Gender:

Role

Location:

E-mail:

Name

Gender:

Role

Location:

E-mail:

Please provide a detailed description of the incident/situation. (How, when, where the incident occurred.)

What is your role in the situation:

Upload a Photo (Total File Size Allowed 7MB)

May we contact you for additional information?

Yes by Email

Yes by Phone

JavaScript needs to be enabled in your browser

You need to enable JavaScript before you can complete this form. Contact the Service Desk at 651-631-5699 or servicedesk@unwsp.edu if you are unsure how to enable JavaScript.