Interpersonal Violence Report Form

Interpersonal Violence Report

Information on the Person Making the Report (OPTIONAL):

Information on the Survivor:


Information on the Perpetrator:

Did the survivor know his/her perpetrator?
Is the perpetrator affiliated with any campus organization?

Information on the Incident:

Where did the incident occur?
Type of Incident
Does the survivor believe he/she was drugged?
Was a weapon used?
Was the perpetrator using drugs or alcohol?
Does the assaulted person plan to seek disciplinary action through USC Upstate?
Does the assaulted person plan to contact law enforcement?
Survivor has been advised of the following resources (check all that apply)