Unofficial and Anonymous Report Form

In order to better track campus violence and sexual assault on campus, this form has been designed to anonymously report campus violence and sexual assault experiences. This information will be shared with relevant campus offices to develop appropriate campus resources and response. This is not an official report, nor does it mean that you will be required to report to the police. If you would like to talk with someone about reporting and response, be sure to fill out the box at the end of the form with your name and other contact information. You would then be contacted by the office you indicate.

1. Date of incident:     Date of this report:
Time of incident (AM/PM):
Location of incident:
(Residence Hall, Fraternity, Off-campus, etc.-- Do not use specific room/house numbers.)

2. Was the incident a(n): (check all that apply)
   Act of Violence (please explain: fighting, relationship violence)
   Stalking, sexual harassment, threat/intimidation, or other (please explain)
   Sexual abuse- sexual contact and no intercourse
   Date rape/Acquaintance rape- sexual intercourse or penetration without consent by someone the victim/survivor dated, knows or has just met
   Stranger rape- sexual intercourse or penetration without consent by someone the victim/survivor does not know
   Sexual intercourse or penetration without consent by two or more attackers

3. Were drugs involved?    Yes    No   I don't know

3. Was alcohol involved?    Yes    No    I don't know

5. Is the victim/survivor:
Female    Male    Student (year  ) Non-Student

6. Is the perpetrator:
Female    Male    Student (year  ) Non-Student

9. Description of incident. (You need not include information which may reveal identities of involved parties).