Sexual Violence Reporting Form

Reports can be submitted through this website at any time; however, if a situation is urgent or you have immediate safety concerns, notify MTSU University Police (on campus: 615-898-2424) (off campus: 911) or call the Rutherford County Domestic Violence & Sexual Assault Program at 615-494-9262.

Incident Information

Date of Incident (If applicable and known. Otherwise, leave blank and explain below.)

MM slash DD slash YYYY

Location of Incident

Incident Description

Person Reporting

Name

(leave blank if you wish to report anonymously)

First Last

Daytime Phone

Relationship of person reporting to the parties involved

Person Harmed

Name

(if known)

First Last

Daytime Phone

Status

Student

Employee

Other

Are the persons involved in this incident aware a report is being made?

Yes

Any other person harmed?

Yes

If yes, provide information

Person(s) Accused

Name (if known)

Daytime Phone

Status

Student

Employee

Other

Is person aware this report is being made?

Yes

Any other person accused?

Yes

If yes, provide information

Law Enforcement Involvement

Has law enforcement been notified?

Yes

Unknown

Reported Complaint

Inserting your name in the box below signifies your official signature. An official signature indicates you are submitting a formal complaint to Middle Tennessee State University. No signature indicates that you would like to discuss the matter with the Title IX Coordinator as soon as possible.

Signature

Name

This field is for validation purposes and should be left unchanged.