The purpose of this form is to provide Members of the University Community with an alternative to face-to-face disclosing about an incident of sexual violence. This will also help Student Affairs to better understand the current state of our campus and help to improve safety in our community.

Non-emergency Only

This form is not to be used as an emergency response. 

If this is an emergency situation, please dial 911 or contact Campus Security at 604 984 1763. 

Thank you





  •  Student
  •  Faculty
  •  Staff
  •  Other


Would you like to be contacted?



  • If you would like the Community Wellness Strategist to contact you, please select “Yes” to the question “Would you like to be contacted?” (below) AND provide your contact information. (Faculty and staff, please select this option if you are looking for resources and information.)
  • Select “No” if you do not want to be contacted. We do encourage you to still seek support on or off campus. Please see our support resources section.**

    If you choose to remain anonymous, Student affairs will take your disclosure for informational purposes only. There may be no follow-up or action taken.

When you submit this form, it will go directly to the University’s Community Wellness Strategist in Student Affairs. Please refer to the list of on and off campus supports for victims of sexual violence. 

By allowing us to contact you, we will also be able to support you more directly through the process.

This form is to be used for the following:

  • Members of the University Community to provide information about an incident of sexual violence, whether it occurred to them or someone else.
  • Faculty and staff to request additional resources and guidance when they have received a disclosure from a student.
  • Students who wish to begin a formal report, but want to start the process, not face-to-face.

Please contact the Community Wellness Strategist at 604 986 1911 ext 3584 to set up an in-person meeting, or for more information about this and other resources available in response to the Sexual violence and misconduct policy (pdf) at Capilano University.

Your privacy matters

Personal information on this form is collected under the authority of the B.C. Freedom of Information and Privacy Act (“FIPPA”) and the University Act. This information is used only for the purposes stated at the beginning of the form. Your information will remain confidential, and will only be used or disclosed as authorized under the FIPPA. Should you have any questions about the collection and use of this information, please contact the