Sexual Assault Claim Form

SEXUAL ASSAULT CLAIM FORM

Claimant Name:    Claimant Address:

Respondent Name:    Respondent Relationship/Role:

Date of Incident:    Time of Incident:    Location of Incident:

Claim Reference Number (if assigned):

RECITALS

WHEREAS, Claimant asserts that on the date and location stated above Respondent engaged in conduct constituting sexual assault as defined by applicable law and institutional policy, and that such conduct has caused harm to Claimant; and

WHEREAS, Claimant seeks to provide a written statement, identify witnesses and evidence, and authorize the release of records necessary for a prompt, thorough, and fair investigation and any related proceedings; and

WHEREAS, Respondent will be provided notice of the claim and an opportunity to respond in accordance with procedural safeguards required by law and the governing policies of the applicable entity;

NOW THEREFORE, the parties submit the following information and attestations to document the claim and authorize the actions described herein.

1. STATEMENT OF CLAIM

Claimant is required to provide a detailed factual narrative of the alleged conduct. The statement should identify persons present, actions taken by the parties, and any immediate steps following the incident. Attach supplemental pages if necessary.

2. EVIDENCE AND WITNESSES

Provide a list of known witnesses, the nature of testimony expected, and a description of physical or documentary evidence. Indicate whether evidence is in Claimant's possession, with a third party, or is to be collected by investigators.

3. RELIEF SOUGHT

Claimant may specify the remedies or protections being requested. The entity handling this claim will evaluate requested relief consistent with applicable policy and law.

4. AUTHORIZATIONS AND RELEASES

By signing below Claimant authorizes disclosure of records necessary for investigation and related proceedings. This authorization is limited to the records and time period described and does not waive privileges beyond the minimum necessary information.

Medical records
Counseling and treatment records
Academic or employment records
Electronic communications and device evidence

5. CONFIDENTIALITY AND DISCLOSURE

Information provided in this form and obtained during the investigation will be treated as confidential to the extent permitted by law. Confidentiality does not prevent disclosure when required by law, when necessary to protect safety, or when disclosure is required for due process in disciplinary proceedings.

6. COOPERATION WITH INVESTIGATION

Claimant agrees to cooperate reasonably with investigators, provide truthful statements, and identify witnesses or documents known to Claimant. Failure to cooperate may affect the investigation and any remedies available.

Yes

7. REPRESENTATIONS AND CERTIFICATION

Claimant certifies that the information provided in this form is true and accurate to the best of Claimant's knowledge and belief. Claimant understands that knowingly providing false statements in connection with this claim may result in disciplinary action and may be subject to civil or criminal penalties under applicable law.

8. NOTICES

All notices, requests, consents and other communications required or permitted under this form shall be in writing and delivered to the addresses or contact points provided below.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

Governing Law: This claim form and any related investigative or administrative proceedings shall be governed by the laws applicable to the entity receiving and processing the claim, without regard to conflict of law principles.

Entire Agreement: This form constitutes the complete written statement of the Claimant's allegations and authorizations described herein. Any prior written or oral statements related to the same claim are superseded unless expressly incorporated in writing.

Severability: If any provision of this form is found to be unenforceable, invalid, or illegal, the remainder of the form shall remain in full force and effect and shall be construed to give effect to the parties' intent to the fullest extent permitted by law.

10. AMENDMENTS; WAIVER; COUNTERPARTS

Amendments: Any amendment or modification to this form must be made in writing and signed by Claimant and an authorized representative of the investigating entity where required.

Waiver: A failure to insist on strict performance of any provision of this form shall not be considered a waiver of any right hereunder.

Counterparts: This form may be executed in counterparts, each of which shall be considered an original, and all of which together shall constitute one instrument.

CERTIFICATION

By signing below, each signing party certifies under penalty of perjury that the information provided in this form is true, complete, and correct to the best of that party's knowledge, and authorizes the disclosures and actions described herein for purposes of investigation and resolution.

Sign Now