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DIVERSITY & INCLUSION Policies and Procedures
39.03 NSCC Sexual Violence Report Form
FORM
Executive Policy Sponsor:
VP, Organizational Development
Policy Steward:
Director, Diversity & Inclusion
Approved:
Executive Council
May 8, 2018
Effective Date:
MAY 2018
Next Review:
MAY 2022
Page 1 of 3
1.0 PURPOSE
The purpose of this form is to report Sexual Violence occurring between members of the College
community. A report may be made by any member of the College community. The process to make a
Report is outlined in the Sexual Violence Procedures. When a student is reporting, please forward this form
to your Manager of Student Services. When an employee or non-student is reporting, please forward this
form to your manager. Reports may also be sent directly to the Director of Diversity & Inclusion as outlined
in the Sexual Violence Procedures.
This form is not used to document disclosures of sexual violence made to a counsellor which are held in
confidence with limited exceptions.
NSCC recognizes that confidentiality is important to those who report Sexual Violence. NSCC will take
reasonable precautions to maintain confidentiality, within the limitations described in the Sexual Violence
Policy. Where possible, any questions or concerns about confidentiality should be posed to a College
representative prior to making a Report. Confidentiality does not mean anonymity. The College’s ability to
respond may be limited where a Report is filed anonymously.
Data, excluding any personal or identifying information, regarding patterns and trends in Reports under this
policy may be aggregated, analyzed and shared within the College for the purpose of maintaining a safe
working and learning environment.
1. Complainant’s Information (the person making this Report):
Complainant’s Name:
Complainant’s Affiliation to NSCC (student, employee, other- please specify):
Complainant’s NSCC ID # (if applicable):
Complainant’s Campus (if applicable):
Complainant’s Telephone Number:
Complainant’s Email:
2. Victim/Survivor’s Information (if different from Complainant)
Victim/Survivor’s Name:
Victim/Survivor’s Affiliation to NSCC (student, employee, other- please specify):
Victim/Survivor’s NSCC ID # (if applicable):
DIVERSITY & INCLUSION Policies and Procedures
39.03 NSCC Sexual Violence Report Form
FORM
Executive Policy Sponsor:
VP, Organizational Development
Policy Steward:
Director, Diversity & Inclusion
Approved:
Executive Council
May 8, 2018
Effective Date:
MAY 2018
Next Review:
MAY 2022
Page 2 of 3
Victim/Survivor’s Campus (if applicable):
Victim/Survivor’s Telephone Number:
Victim/Survivor’s Email:
3. Respondent’s Information (the person(s) alleged to have perpetrated Sexual Violence)
Respondent’s Name (if known):
Respondent’s Affiliation to NSCC (student, employee, other- please specify):
4. Description of What Happened
Date(s) of Occurrence(s) and Time of Day:
Location(s) where Sexual Violence occurred (please be specific)
Description of What Happened (nature of conduct, context or circumstances such as campus event,
off-campus event, who else was present, etc.):
Attach additional pages if more space is needed.
DIVE
RSITY & INCLUSION Policies and Procedures
39.03 NSCC Sexual Violence Report Form
FORM
Executive Policy Sponsor:
VP, Organizational Development
Policy Steward:
Director, Diversity & Inclusion
Approved:
Executive Council
May 8, 2018
Effective Date:
MAY 2018
Next Review:
MAY 2022
Page 3 of 3
Has this matter been reported to the police?
N/A No Yes
If yes, please list the Report #: _________________________
Has t
his matter been reported to another College Employee?
N/A No Yes
If yes, please indicate whom: ________________
Details:
5. Action Taken and by Whom
Pleas
e describe any actions taken to address/resolve this matter:
Complainant’s Signature:
6. Signature of Staff Receiving Form
Nam
e: Position:
Sig
nature: Date:
I understand that checking this box constitutes an electronic signature
I understand that checking this box constitutes an electronic signature
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Completed 22 July 2021

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