SASH INCIDENT FORM
This form is to be completed by any member of the NTI community who experiences sexual harassment or sexual assault. This form should also be completed by members of the NTI community who witness or become aware of incidents of sexual assault or sexual harassment. Please consult NTI’s Prevention of Sexual Assault and Sexual Harassment Policy via the Student Policy Library on NTI website www.nantien.edu.au/current-students.
Do you want to remain anonymous?
I / we prefer to remain anonymous
Name
First Name
Last Name
Contact Details
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you reporting for yourself or someone else?
Myself
Someone else – name, if known:
Name if known
Details of the incident
Location of the occurrence:
Date and time of the incident:
-
Month
-
Day
Year
Date
Which of the following do you wish to report (you can select more than one option)?
Unwanted, unwelcome, or uninvited behaviour of a sexual nature
Sexual assault
Sexual battery
Sexual violence
Stalking
Rape
Other (including attempts to commit any of the above acts)
I am a:
NTI student
NTI staff member
Other
If you are reporting on behalf of another person, do you have their permission?
Yes
No
I am reporting my matter
The questions below relate to the perpetrator/s (person/s suspected of wrongful behaviour)
Full name/s of the alleged perpetrator/s (if known):
Contact details of the alleged perpetrator/s (if known):
You think they are:
NTI student
NTI staff member
A member of the public
I don’t know
I prefer not to say
Describe the event/s that led you to make this report:
Any other comments of information you would like to share:
Important Note
Important note: The information you provide will be received by the NTI Student Services and Academic Support Manager and will be kept safe and secure. NTI might contact you (if you have provided contact details) to check on the safety and wellbeing of yourself and anyone else affected. If the NTI Student Services and Academic Support Manager believes there is a significant risk of harm to an individual or the community, he/she will escalate the matter to the NTI President or NTI Academic Dean who will refer the details to the Police. If the report is about someone who is under 18 years of age, mandatory reporting applies and NTI staff must inform the Police. In these cases, NTI will notify you immediately about this action and you will be informed if you have to participate in the police enquiry. More information can be found on NTI website and in the Student Policy Library.
Date this form is submitted:
-
Month
-
Day
Year
Date
Please submit this form and any available supporting documents to Nan Tien Institute at report@nantien.edu.au.
Submit
Should be Empty: