Sexual Assault/Violence Reporting

Today's Date*

Your Information

Please check*

if you are the victim/survivor of sexual assault / violence ?
if you reporting sexual assault / violence but you are NOT the victim/survivor ?

Do you wish to report an incident anonymously?

Yes
No

Your Name

First Last

Your Email Address

Enter Email Confirm Email

NOTE: A confirmation email will be sent to this email address when this form is completed.

Phone Number

This phone number will be used to follow up with you within 72 hours. We may leave you a voicemail.

Your Relationship to the College*

Student
Staff
Other

Incident Information

Date of Incident*

Time of Incident*

:

Nature Of Sexual Assault/ Violence. Please check all that apply.*

Sexual Assault - A criminal offence under the Criminal Code of Canada. Sexual assault is any type of unwanted sexual act done by one person to another that violates the sexual integrity of the victim and involves a range of behaviours from unwanted touching to penetration.
Sexual Harassment - Any unwanted or offensive sexual behavior that creates a hostile or stressful living, learning, or working environment. Examples of sexual harassment include: unwanted sexual advances, unwanted or uninvited touching, sexual retaliation or threats, sexual jokes or comments, sexual leering, whistling, or gestures, the displaying of sexually suggestive images. Sexual harassment can be a single incident or an ongoing pattern of behaviour.
Stalking - A form of criminal harassment prohibited (face to face, phone, email, social media); threatening or obscene gestures; surveillance; sending unsolicited gifts; “creeping” via social media/cyber-stalking; and uttering threats.by the Criminal Code of Canada. It involves behaviours that occur on more than one occasion and which collectively instill fear in the survivor or threaten the survivor/target’s safety or mental health. Stalking can also include threats of harm to the target’s friends and/or family. These behaviours include, but are not limited to non-consensual communications
Indecent Exposure - The exposure of the private or intimate parts of the body in a lewd manner, when the perpetrator may be readily observed.
Voyeurism - Observing another in a sexual manner without consent and when they could reasonably expect privacy. This includes direct observation, through the use of an electronic or mechanical device, or through the use of a recording.
Sexual Exploitation - Seeking benefit through the non-consensual or abusive sexual control over another.
Chose not to disclose

Other than those described above. Please specify.

Number Of Offender(s).*

Name(s) of Offender ( if known).

Offender relations to victim/survivor.*

Partner, girlfriend, boyfriend
Friend
Ex-partner, ex-girlfriend, ex-boyfriend
Faculty
Staff member
Colleague or Co-worker
Acquaintance
Stranger

Gender of the Offender(s)*

Male
Female
Multiple Males
Multiple Females
Males and Females
Unknown

Offender's relationship to Algonquin College*

Student
Staff
Unknown

Location of Incident. Please check all that apply.

On Algonquin College Campus
In Algonquin College Residence
Off campus at a college sanctioned activity
Off campus and unrelated to the college
In the Offender's room
In the Victim/Survivor's room
In a Classroom
In an Car
Outdoors

Was the victim/survivor given alcohol and/or drugs without consent or knowledge?*

Yes, alcohol
Yes, drugs
No
Unknown

Was the victim/survivor pressured to consume drugs/alcohol?

Yes
No

Incident Description - Briefly describe what happened below*

Have the Police been contacted?*

Yes
No

If yes, enter police force and file number below:

Do you wish to have assistance in contacting the police?*

Yes
No

Is your education or employment at Algonquin College being impacted due to this incident?*

Yes
No

If you are a student you are strongly encouraged to talk to Counselling Services, Health Services, or your program Chair to discuss options for accommodation and/or support. For more information regarding the process please contact Security Services at 613-727-4723 ext. 5010. If you are staff or an employee you are strongly encouraged to speak with your Supervisor or Human Resources.

Name

This field is for validation purposes and should be left unchanged.

Police	911
Counselling Services (Ottawa Campus)	613-727-4723 ext. 7200
Counselling Services (Perth Campus)	613 267-2859 ext 5610
Counselling Services (Pembroke Campus)	613-735-4700, Ext. 2804
Health Services (Ottawa Campus)	613-727-4723 ext. 7222
Health Services (Perth Campus)	613-267-2859, ext. 5604
Health Services (Pembroke Campus)	613-735-4700 ext. 2748

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Risk Management

Sexual Assault/Violence Reporting

Purpose

Why would I fill out this form?

What if I wish to remain anonymous?

What if I would like to speak to someone in person?

What happens with this information?

What is Sexual Assault?

What is Sexual Violence?

Sexual Assault / Sexual Violence Report

Your Information

Incident Information

Ottawa

Pembroke

Perth

Online