Sexual Misconduct Initial Report Form

(Sex & Gender Discrimination / Sexual Misconduct or Violence)

Submissions can made by Stony Brook Medicine and individuals outside of the Stony Brook Community. Submission will be made to Marjolie Leonard, Assistant Vice President, Title IX and ADA Coordinator, Office of Equity and Access.

Your Contact Information

Please identify your relationship to the university:

If other (Please Explain)

Name

Are you reporting for yourself?

Contact Information for Victim

Complainant/Victim is a :

If other (Please explain)

Name

Contact Information

Contact Information for Respondent/Accused

Respondent/Accused is a:

If other (Please explain)

Name (If known)

Contact Information (If known)

Reporting

Where the incident occurred?

If other (Please explain)

Incident occurred within a residence hall?

Date and Time of Incident

You are reporting:

Please describe, with as much detail as possible, the incident you would like to report: If you are uncomfortable in adding this information, you may type "Would like to speak to someone".

Certification

If you would like a copy of this form, please provide your email.

Signature (Type your name)

By submitting this form I am certifying the above statements to be true and factual to the best of my knowledge.