ANONYMOUS REPORTING FORM
This form is designed to provide Eastern Florida State College students, employees, faculty, and others with a method to
anonymously report crimes or allegations of Sexual Misconduct. You are not required to complete the entire form to
submit it, but you are required to submit the form in good faith, with information that is true and accurate to the best of
your knowledge. Anonymous reports will be investigated, however, the College’s response may be limited depending on
the information provided.
Be advised that anyone who is or can be identified by the information provided may be contacted by the College as
part of the investigation, and that some or all of the information provided may be shared with the person(s) being
accused of committing crime or Sexual Misconduct. If you do not want to be identified, omit your personally
identifiable information throughout the form. If the person completing this form is a third party who is not the victim,
do not include any personally identifiable information about the victim unless you have the victim’s express permission
to disclose his or her identity.
Provide information about the incident(s) being reported.
Type of Incident:
Date of Incident:
Time of Incident:
Location of incident (if incident occurred on EFSC property, identify which campus, building, parking lot, etc.):
Description of Incident:
Provide information about the person(s) accused of committing crime and/or Sexual Misconduct.
Provide information about any person(s) who witnessed the incident(s).
Provide what action, if anything, you are requesting be taken as a result of the incident(s).
WHERE DOES THIS FORM GO?
WHEN COMPLETED, SUBMIT THIS FORM TO ANY CAMPUS SECURITY OFFICE. YOU MAY SUBMIT VIA U.S. MAIL, CAMPUS MAIL,
FAX, HAND DELIVERY, OR OTHER METHOD. IF YOU SUBMIT VIA HAND DELIVERY, YOU WILL NOT BE REQUIRED TO PROVIDE
YOUR NAME. IF YOU SUBMIT VIA FAX, CALL: (321) 433-7729.
Cocoa Campus Security
1519 Clearlake Road
Building 1, Front Lobby
Cocoa, FL 32922
Melbourne Campus Security
3865 N. Wickham Road
Building 1, Room 123
Melbourne, FL 32935
Palm Bay Campus Security
250 Community College Pkwy.,
Bldg. 1, Room 101B
Palm Bay, FL 32909
1311 N. U.S. 1
Building 1, Room 101A
Titusville, FL 32796
-------------------------------------------FOR ADMINISTRATIVE USE ONLY---------------------------------------------------
DATE REPORT RECEIVED:
HOW REPORT WAS RECEIVED:
NAME OF PERSON RECEIVING REPORT:
***NOTIFY THE CAMPUS SERGEANT AND CHIEF OF SECURITY IMMEDIATELY UPON RECEIPT OF THIS REPORT.