Incident Report

Report Day (yyyy.mm.dd):                             Incident Number:

Advisor:          (Signature)

Complainant
Name		Gender			Date of Birth
Department/Affiliation			Student ID Number or Position
Address
Contact Number	☏ Mobile:			E-mail
Victim (If you are the complainant, you do not have to fill out this part)
Name		Gender			Date of Birth
Department/Affiliation			Student ID Number or Position
Address
Contact Number	☏ Mobile:			E-mail
If you are not a victim, do you have the victim’s consent for this incident report? Yes □ No □
Respondent
Name		Gender			Date of Birth
Department/Affiliation			Student ID Number or Position
Address
Contact Number	☏ Mobile:			E-mail
*Please, write as much information as possible about respondent, that may help our investigation.

1. Facts about the Incident

① When:

② Where:

③ Relationship of the Respondent with the Victim :

In a Relationship □    Friend or Senior/Junior □      Faculty □

Administrative Staff □    Others □ (Please specify:          )

④ Please, outline the nature of the incident.

⑤ How did the victim respond when the incident happened:

* If the incident is related to verbal or physical conduct of sexual nature, please check any of the below that may apply.

Took no action □

Verbal resistance □

Physical resistance □

Verbal and physical resistance □

⑥ How did the respondent react to the victim’s action described above?

⑦ Please check which remedy the victim wants.

Disciplinary Procedures as defined by the University Regulation □

Legal remedy □

Informal remedy □

Others □ (Please, specify )

2. Witness

- If you know anyone who witnessed the incident, please list their names.

3. Attachments

- If you have any materials which may support your claim regarding the incident, please attach them to this Incident Report and provide a list of those materials here.

* Consent for use of personal information

Your personal information will be used only for our counselling service. At the end of the service, your personal information will be discarded.

I Agree. □

Complainant (Signature)

SNU Human Rights Center

Sexual Harassment and Violence Counselling Line / Human Rights Counselling Line