CUHAS Anonymous Gender-Based Violence & Harassment Reporting Form

Your safety matters. You may submit this form anonymously. Only the CUHAS Gender Desk Officer and the Vice Chancellor will review your report.

How to use this form: Share what you’re comfortable with. You may remain fully anonymous. If you’d like follow-up, provide contact details below. Your privacy is protected at all times.

2. Sex

Male

Female

Prefer not to say

3. Age (years)

4. Programme

5. Year of Study

1st

2nd

3rd

4th

5th

5. Department/School

6. Date of Incident

7. Time of Incident (if known)

8. Location of Incident

On Campus

Off Campus

9. Type(s) of Incident (check all that apply)

Physical assault

Sexual harassment

Verbal abuse

Cyber harassment

Stalking

Gender discrimination

10–12. Perpetrator Information (if known)

Relationship

Perpetrator’s Department (if known)

Name of Perpetrator (if known)

13. Method(s) Used (check all that apply)

Threat of failing or poor grades

Promise of reward

Physical intimidation

Verbal threats

Online harassment

14–15. Prior Reporting

Yes

16–17. Would you like follow-up contact?

Yes (provide email/phone below)

18. Additional Information (optional)

Consent and Declaration

I understand this report is anonymous unless I provide contact details, and it will be reviewed only by authorized CUHAS officials without any penalties to me.

I acknowledge that providing false information may affect the investigation process.

Privacy: This page should be served over HTTPS. For full anonymity, ensure the server does not store IP addresses or other identifiers in access logs.

Frequently Asked Questions (FAQ)

Yes. You don’t have to share your name or contact details unless you want to.

Your report is reviewed confidentially by the Gender Desk officer and the Vice Chancellor. If you left contact info, we may reach out to offer support.

Absolutely. Only authorized CUHAS officials will access your report. Your information will not be shared without your consent.

You can still provide your contact details anonymously to receive support from the Gender Desk, or contact them directly for confidential help.

Any form of gender-based violence or harassment including physical, sexual, verbal, cyber, stalking, or discrimination.

Yes. The Gender Desk handles reports involving any CUHAS/BMC/MWACHAS community member or visitor.

CUHAS Anonymous Gender-Based Violence & Harassment Reporting Form

Frequently Asked Questions (FAQ)

Q1: Can I report anonymously?

Q2: What happens after I submit the form?

Q3: Will my identity be kept private?

Q4: What if I don’t want to report but just want help?

Q5: What types of incidents should I report?

Q6: Can I report incidents involving staff or students?