Delta State University, Abraka

Your report will be handled with confidentiality and care

Name (Optional)

Nature of Abuse *

Physical Abuse

Verbal/Emotional Abuse

Sexual Assault

Stalking

Other

Please specify other abuse type

Position of Perpetrator *

Academic Staff

Non Teaching Staff

Student

Other

Please specify other position

Faculty of Perpetrator

Department of Perpetrator

Unit of Perpetrator

Name of Perpetrator (Optional)

Date/Time of Incident *

Location of Incident *

Description of What Happened *

Specify If any physical injuries sustained *

Did the victim seek medical attention? *

Did the victim report to authorities? *

Were there any witnesses?

Please specify

Contact information of witnesses (if available)

Any other information the victim wishes to share

Upload Evidence (optional)

Upload a file

or drag and drop

PNG, JPG, PDF, MP3, MP4 up to 100MB

Please verify you're human *

Your information is secure and confidential