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Campus Incident Reporting Form (for Sexual Misconduct and Clery Violations)


Please Note: Information gathered from these forms will not result in a police investigation. If you want to report a crime to law enforcement, please call UWPD at 911 or 608-264-2677 (COPS), or come to UWPD at 1429 Monroe St., Madison, WI. UWPD is open 24 hours a day, every day of the year.

If you have personally experienced sexual harassment, sexual assault, dating/domestic violence, stalking or sexual exploitation, you may want to review information about support resources, protective measures, accommodations, and response options available to you before completing this reporting form.

If you then choose to complete the form below, you will be contacted by someone from the Title IX Program who will provide you with additional information about resources and response options.

If you are otherwise reporting in compliance with campus requirements, completing this form allows employees to meet the reporting requirements listed below:

  • Campus Security Authorities (CSAs) : Designated in compliance with the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act (Clery Act). Required to report certain crimes that occur on campus geography. For information regarding the Clery Act's Campus Security Authority reporting responsibilities,click here.
  • Responsible Employees (REs): Designated in compliance with campus policy. Required to report any information that suggestions a violation of the UW-Madison Policy on Sexual Harassment and Sexual Violence. For more information regarding RE’s reporting requirements,click here.
  • All UW Employees: Required to report sexual assaults involving a student. For information regarding Wisconsin's sexual assault reporting responsibilities for employees (WI § 36.11(22)(c)),click here.


The purpose of this form is to collect crime and referral statistics and to inform UW-Madison of crimes so that UW-Madison can follow-up with action when appropriate. Information gathered may also result in an investigation by the Office of Student Conduct and Community Standards or the Office of Compliance. Statistical information gathered may be reported in UW-Madison's Annual Security and Fire Safety Report.

Please provide the victim/complainant, if known, a copy of the appropriate resource listed above. For youth victims/complainants, provid the Youth & Families Resource Guide to their parent or guardian. 

Reminder: You DO NOT need to know all the answers to the questions below. If you completing the form to meet your reporting requirement, you are NOT expected to investigate further or ask people involved specific questions in order to fill out this form completely.

For questions, call Mickey Kienast at (608) 262-0139.

Background Information

 
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Victim/Complainant

Involved party 1

Additional Questions

What is the type of incident or crime being reported? Link to definitions: click here.(Required)
You must make at least one selection.
Is this a dating/domestic violence incident?(Required)
You must make at least one selection.
Is or was there an intimate partner relationship between the victim and the offender?(Required)
You must make at least one selection.
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Is the incident or crime a hate crime? (A hate crime is a criminal offense committed against a person or property which is motivated, in part, by the offender's bias. Categories protected include: race, gender, religion, sexual orientation, disability, gender identity, ethnicity, and national origin). Please include what protected class the hate crime was against in the narrative portion below.(Required)
You must make at least one selection.
Certain student and employee violations referred to the Dean of Students Office, Human Resources Office, or individual supervisors must be reported. If you are reporting any of the violations listed below, please check the appropriate box and if more than one person is being referred, please indicate the number of people in the narrative box below.(Required)
You must make at least one selection.
Has the incident or crime been reported to other agencies (check all that apply)?(Required)
You must make at least one selection.
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Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission