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1
SEXUAL MISCONDUCT REPORTING FORM FOR COLLEGE EMPLOYEES
This form is to be used by any College employee who receives information about an
incident of alleged Sexual Misconduct.
PLEASE READ INSTRUCTIONS BEFORE USING FORM
1. If there is an ongoing threat to the College community, or if any person requires immediate medical
attention, call 911. Then call the Campus Security office on the appropriate campus.
2. Ask the person who endured the incident if they want to call the police. Advise the person of their right
to contact or not to contact the police. If the person has questions about whether or not they should call
the police, DO NOT GIVE THEM ADVICE but rather explain their right, and further explain that the College
encourages police involvement any time alleged misconduct is of a serious nature. If the person requests
your help in calling the police, give them help.
3. If the incident recently occurred, and if appropriate, make sure the person understands the importance of
preserving evidence and suggest they not bathe, douche, brush teeth, wash hands, change clothes, go to
the bathroom, eat, drink, or take any medication until they have received proper medical attention.
4. Provide the person with a copy of the College's Sexual Misconduct Resource Guide.
5. Before the person reveals any details of the incident to you, make sure the person understands that you
are required to report any information you receive to other College officials. If the person wants to keep
the matter strictly confidential, politely suggest that the person may want to speak with someone other
than yourself, such as a counselor or advocate, as you are required to notify other College officials.
6. If the person wishes to continue speaking with you, go through each of the questions in this form, asking
the person to provide as much detail as they feel comfortable. Ask the person to sign the form at the end.
7. After you have completed the form, explain to the person that appropriate College officials will follow up
to discuss the information provided and determine appropriate next steps.
8. WHEN THE ENCOUNTER IS OVER, IMMEDIATELY SUBMIT A COPY OF THIS FORM TO EACH OF
THE FOLLOWING PERSONS. YOU MAY SUBMIT VIA FAX, E-MAIL, OR HAND DELIVERY; HOWEVER
PLEASE FOLLOW UP WITH A TELEPHONE CALL TO EACH PERSON TO CONFIRM RECEIPT. IF AFTER HOURS
OR WHEN THE COLLEGE IS CLOSED, SUBMIT THE FORM TO THE NEAREST CAMPUS SECURITY OFFICE.
Mark Renkens
Title IX Compliance Coordinator
Melbourne Campus, Bldg. 10, Room 215
Phone: (321) 433-7180
Fax: (321) 433-5026
E-Mail: renkensm@easternflorida.edu
Darla Ferguson
AVP H.R. and Chief Equity & Diversity
Cocoa Campus, Bldg. 2, Room 113
Phone: (321) 433-7080
Fax: (321) 433-7685
E-Mail: fergusond@easternflorida.edu
Joe Ambrose
Chief of Security
Melbourne Campus, Bldg. 8, Room 201
Phone: (321) 433-7007
Fax: (321) 433-5026
E-Mail: ambrosej@easternflorida.edu
2
SEXUAL MISCONDUCT REPORTING FORM FOR COLLEGE EMPLOYEES
Reporting Party (this is the person who is providing information to the EFSC employee)
Are you: The Victim
A Third Party
If you are a Third Party, does the
Victim know you are making this
report? Yes No N/A
Are you a: Student Employee
Faculty Other_____________
First Name:
Last Name:
Address:
City:
Zip:
Phone Number:
E-Mail Address:
Gender:
Race:
Age:
Victim (if not the same person as the Reporting Party)
Is the Victim a: Student Employee Faculty
Other______________________________________
Victim’s Age:
First Name:
Last Name:
Address:
City:
Zip:
Phone Number:
E-Mail Address:
Gender:
Race:
Age:
Law Enforcement
Was the incident reported to any law enforcement agency? If so, which agency?
Does the Victim want the incident reported to law enforcement? Yes No Unknown
Does the Victim request assistance with reporting the incident to law enforcement? Yes No Unknown
Other Reports
Has the Victim reported the incident to anyone else? Yes No Unknown (if the answer is “yes” please list
the names and contact information below)
Incident
Date of Incident:
Time of Incident:
Location of incident (if incident occurred on EFSC property, identify which campus, building, parking lot, etc.):
3
Description of incident:
Responding Party (information about the accused; use separate pages if multiple persons accused)
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone Number:
E-Mail Address:
Gender:
Race:
Age:
Is this person a student, employee, or faculty of EFSC? Yes No Unknown
Is this person an acquaintance of the Victim? Yes No Unknown (if the answer is “yes” describe the
relationship between the Responding Party and the Victim)
Witnesses (information about any witnesses; use separate pages if multiple witnesses)
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone Number:
E-Mail Address:
Age of the Witness:
Is this person a student, employee, or faculty of EFSC? Yes No Unknown
Medical Treatment
Did the Victim receive any medical treatment after the incident? Yes No Unknown (if the answer is
“yes” please indicate when and where the Victim received treatment below)
4
Evidence
Did the Victim preserve any evidence involving the incident? Yes No Unknown (if the answer is “yes”
please describe the evidence and identify the person(s) who have current possession of it below)
Alcohol or Drugs
Was either party under the influence of alcohol or other drugs at the time of the incident? Yes No
Unknown (if the answer is “yes” please describe the nature and extent of influence below)
Weapons
Were any weapons used during the incident? Yes No Unknown (if the answer is “yes” please describe the
weapons below)
Hate Crime Assessment
Is there any evidence that the incident was motivated by the Victim’s race, gender, gender identity, religion,
sexual orientation, ethnicity, national origin, or disability? Yes No Unknown (if the answer is “yes” please
describe which category of bias and supporting evidence below)
Threat Assessment
Is there reason to believe this incident represents a present or continuing threat of harm or danger to the Victim
or other member(s) of the College community? Yes No Unknown (if the answer is “yes” please describe
the threat below)
Resource Guide
Has the Victim received a copy of the EFSC Sexual Misconduct Resource Guide? Yes No (if the answer is
“no”, it is strongly encouraged that the Victim read the Resource Guide, which is available on the College website)
5
Immediate Accommodations
At this time, does the Victim request any immediate accommodations from EFSC, such as a campus no-contact
order, or changes to academic, living, transportation, and/or working situations? Yes No Unknown (if
the answer is “yes” please describe the requests below)
Signature of Reporting Party
I affirm that the information provided above is true and correct to the best of my knowledge.
Date: ___________________ By: __________________________________________
Reporting Party
-------------------------------------------COMPLETED BY EFSC EMPLOYEE--------------------------------------------------
DATE REPORT RECEIVED:
TIME REPORT WAS RECEIVED:
NAME AND CONTACT INFORMATION FOR EFSC EMPLOYEE WHO RECEIVED REPORT:
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Completed 15 August 2020

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