MANDATORY REFERRAL PROCESS (MRP)
This form is to be used only by programs that have instituted a mandatory referral process with specialized training,
such as the MSU Department of Residence Life. Other programs: please refer to the Permission to Contact (PTC) form.
Suggestions for Working with MSU Community Members
Experiencing Relationship Violence, Stalking or Sexual Assault
What should I do if I learn or suspect that someone is experiencing relationship
violence, stalking or sexual assault?
Do not underestimate the potential physical danger that she/he might be in.
The danger a student may be in can be made worse by a university response that does
NOT take safety objectives and planning into consideration, such as reporting the name of
the potential perpetrator to the police when safety measures have not been put in place
with the victimized student.
Helping students make contact with an advocate, counseling and other program services
from the MSU sexual assault program (SAP) or MSU Safe Place (MSUSP) can alleviate
safety risks and provide support.
Do not blame the person for the abuse, violence or threats they have experienced.
Recognize the courage it takes for someone to share something so personal.
Respect their confidentiality.
Explain that because the University cares for the well being and safety of students that
someone from one of the confidential on-campus resources for persons experiencing
relationship violence, stalking or sexual assault will be contacting the student in the next
day or two. Explain that your contact with this program, and the students’ future contact, is
What’s the next step?
Graduate, senior or full time staff or faculty need to complete the MRP form. Fax or e-mail the
completed form to the MSUSP or SAP office, depending on the primary issue affecting the student.
The next business day the appropriate program will contact the student to find out what he or she
needs and offer support and safety objectives and planning. All contact with either MSUSP or SAP
will be kept totally confidential. Identify the primary issue affecting the student and contact either:
MSU Safe Place - FOR RELATIONSHIP VIOLENCE OR STALKING:
Fax: 517- 432-6193, email@example.com, www.msu.edu/~safe, Phone: 517-355-1100 ext. 2
MSU Sexual Assault Program - FOR SEXUAL ASSAULT:
Fax: 517-353-8912, www.endrape.msu.edu, Phone: 517-355-3551
MSU Safe Place and the MSU Sexual Assault Program staff want to thank you for taking time to
read this instruction sheet and for familiarizing yourself with the Mandatory Referral Process (MRP)
instructions. The MRP form is attached.
If you work in a department or unit that does not utilize a mandatory contact process, please
consider using the Permission to Contact (PTC) form. Both the MRP and PTC forms and
instructions can be found on the websites listed above. It is crucial that departments on campus
are equipped with these resources and referral steps and information so that students receive the
support they often need in order to be safe, feel supported and stay enrolled in school.
MCD Rev. Fall 2009
Confidential Program– Relationship Confidential Program- Sexual Assault/Rape:
Safety Violence and Stalking: MSU Safe Place MSU Sexual Assault Program
Advocacy (517) 355-1100 ext. 2 (program business line) (517) 355-3551 (program business line)
Future (517) 432-9570 or 353-9999 (advocacy) (517) 372-6666 (24-hour hotline)
Evolve firstname.lastname@example.org (517) 432-9961 (advocacy)
MANDATORY REFERRAL PROCESS (MRP) FORM
After gathering information from the student who has disclosed that they have been victimized by
relationship violence, stalking and/or sexual assault, complete the form below. Explain to the student that
you want her/him to be be safe, get support and know their options and rights.
TO BE FILLED OUT BY MICHIGAN STATE UNIVERSITY GRADUATE, SENIOR OR FULL TIME STAFF OR
FACULTY, in a program that utilizes a mandatory referral process and has been trained by SAP and/or
MSUSP. (NOTE: For optional contacts for students that disclose to university programs that do not take part
in a mandatory contact process, use of the Permission to Contact (PTC) Form is encouraged. This can be
accessed on either program website.)
(please print information about disclosing student): (please print staff information)
Student’s name:____________________________ Staff/Faculty completing form:___________________
Gender: Female Male Transgender Dept/Unit: ___________________________________
Email: ____________________________________ Address:_____________________________________
ISSUE(S) AFFECTING STUDENT: (check all that apply):
Sexual Assault Stalking Relationship Violence Identify the PRIMARY ISSUE
affecting the student:
Taking into consideration the privacy and safety of the student, check off
For relationship violence or stalking,
contact preferences below. Check all that apply: fax or e-mail form to:
I did speak with the student about contact options. Student prefers:
Phone MSU Safe Place
With a message that you are from MSUSP or SAP FAX: (517) 432-6193 *
With a message with only your first name and phone number EMAIL: email@example.com
Do NOT leave a message
For sexual assault/rape, fax or
e-mail form to:
Visiting with student at their residence or
Leaving a message with their roommate Sexual Assault Program
Contacting the person who completed this form, or someone else that FAX: (517) 353-8912 *
the student trusts to be able to get in contact with them safely: EMAIL: firstname.lastname@example.org
Support person’s name:______________________________________
* Note: faxes come directly into
________________________________________ confidential program offices
I did not speak with the student about contact options.