Sexual Assault Incident Report Form

Sexual Assault Incident Report Form

Reporter's Name

First Name

Last Name

Phone

Date of Report

Victim's age

Victim's academic year

Victim's Gender

Date/Time of Incident

:

Occurred on Campus

Yes No

Where on campus did the assault occur?

Describe the location (name of building, street, etc.)

Describe assault (check one)

sexual contact (fondling, kissing, petting but not penetration) without consent attempted intercourse without consent (penetration did not occur) intercourse (oral, anal, or vaginal penetration by penis or other object) without consent

Other:

Was the absence of consent due to the victim being incapacitated by:

Alcohol?

Yes No

Other drugs?

Yes No

Describe any pressure or force used by the assailant

none verbal pressure or arguments position of authority (boss, teacher, supervisor, etc.) threat of physical force (threatened to hit, hold, or otherwise injure) actual use of physical force (hit, held victim down, twisted arm, etc.) gave victim alcohol or drugs so victim was significantly incapacitated

Was a weapon involved in the assault?

Yes No

Number of assailants

If a single assailant, describe:

Gender

Race

Age

Height

Weight

Role of assailant(s) on campus (check)

student faculty Staff no campus role

Other:

If single assailant, describe nature of relationship with victim prior to the incident (check one)

stranger spontaneous date (i.e., met at bar or party) planned first date relative friend or nonromantic acquaintance of any age romantic acquaintance or on-going date

Name of alleged assailant(s)

Other contact points or departments the victim reported this assault to

Sexual Assault Response Coordinator Student Health Center Residence Life Campus police or security force Counseling Center Sexual Assault Companion/Peer Helper Dean of Students (or other administrator) Local Women's Shelter/Rape Crisis Ctr.

Other:

Name of reporting victim (optional choice of the victim)

First Name

Last Name