Rockford University Anonymous Report Form
Rockford University is committed to providing a safe, secure, and respectful campus environment for our students, faculty, staff, and visitors. To support that goal, this Anonymous Report Form provides a completely anonymous method of sharing information with University personnel. You may also include your name and/or contact information if you choose to do so. If you know of an incident on campus, we would like you to report it. Please fill out the form below. This information will be submitted to the Vice President for Student Life Dean of Students, Director of Public Safety, Director of Human Resources, and Title IX Coordinator. This form is NOT intended for in-progress incidents. If you are currently witnessing an incident, please call Public Safety at 815-226-4060. Please report all in-progress crimes by calling 911 for emergencies and 815-966-2900 for non-emergencies. PLEASE NOTE: you are completing the following form under the condition of anonymity. Your identity is not in any way included with the submission. If you wish to have someone contact you, please include your contact information in the form fields provided.
Incident Information
If date, time and location are unknown, please approximate the date, time and location of the incident.
Date and time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
Location of Incident
*
Please Select
On-Campus
Off-Campus
Online
Specific Location
Involved Parities
If you don't know the parties involved, please provide a detailed description of the people or vehicles.
Name(s)/Description(s)
Incident Details
Please describe the incident in detail
*
Check any of the following personal characteristics that you feel the perpetrators of this incident were targeting (optional):
Sex
Creed
Marital or Family Status
Pregnancy
National or Ethnic Origin
Disability
Gender Identity or Expression
Religion or Religious Affiliation
Veteran Status
Race
Sexual Orientation or Preference
Color
Age
Other
If you listed "other" in the previous question, please specify
List any other individuals or offices to which the incident has been reported (optional)
My relationship to the incident (optional)
I was the target victim
I am a friend or acquaintance of the victim
I am friend or acquaintance of the perpetrator
I witnessed or saw the incident
Other
If you listed "other" in the previous question, please specify
What form(s) did the incident take (optional)
Assault
Interpersonal Violence
Self Harm
Bias-related incident
Sexual Assault
Hazing
Alcohol or Drugs
Stalking
Discrimination
Theft/Burglary
Harassment
Vandalism
Other
If you listed "other" in the previous question, please specify
Relationship to the University (optional)
Student
Faculty
Staff
Alumni
Visitor
Other
If you listed "other" in the previous question, please specify
Your Name (optional)
First Name
Middle Initial
Last Name
Email (optional)
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Address (optional)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you would like to be contacted about this report by phone please list phone number (optional)
If you would like to be contacted about this report by email please list email (optional)
Supporting Documentation
Photos, video, email, and other supporting documents may be attached below.
Supporting Documentation
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: