Sexual Offense Incident Report

Sexual Offense Incident Report

This form is intended to convey information needed to track the University’s response to the incident being reported, as well as to assess the danger the incident represents to the University community at large. All efforts must be made to maintain the victim’s anonymity; no information should be included which might identify the victim. The victim may refuse to answer any or all items on this form: However, the report that a sexual offense occurred must be made. This form is to be forwarded to Dean of Student Services, 224 Elkins Hall.

PART I This information will be used for educational, statistical and preventative purposes.

Reporter’s name Department Phone

Date of report Date of discussion with victim

Victim’s age Academic year Sex

Date of incident Time of incident

Was the absence of consent due to the victim’s being incapacitated by?

Alcohol Yes No

Other drugs Yes No

Other

Describe the nature of the relationship between the victim and the assailants(s) prior to the incident (check one):

Stranger Spontaneous date (i.e., met at party) Planned first date

Friend/non-romantic acquaintance Romantic acquaintance/ongoing date Relative

Other departments or agencies to which the victim reported or plans to report this offense:

Residential Services Campus Police Counseling Center Local Police Student Life VP for Student Affairs

Health Services Other:

Does want to file charges with police

Does not want to file charges with police

Plans to report incident for University judicial proceedings

Does not plan to report for University judicial proceedings

PART II Although the victim’s anonymity will be maintained if she/he chooses not to file charges, the following information may be used (a) in a campus alert in accordance with the Campus Security Act and/or (b) by the University Police.

Occurred on campus? Yes No

If the offense occurred on campus, indicate where:

Residence hall Other campus building Outdoors Automobile

Which hall Which building Where

Describe the sexual offense (check one):

Sexual contact (fondling, kissing, petting, but not penetration) without consent

Intercourse (oral, anal, or vaginal penetration by penis or other object) without consent

Other (describe):

Describe the kind of pressure of force used by the assailant: (check all that apply)

None

Verbal pressure or arguments

Position of authority (boss, teacher, supervisor, etc.)

Threat of physical force (threatened to hit, hold, or otherwise injure)

Actually used physical force (hit, held victim down, twisted arm, etc.)

Gave victim alcohol or drugs so victim was significantly incapacitated

Weapon

Other:

Number of assailants:

Describe: Sex Race Age Height Weight

Role of assailant(s) on campus (check):

Student Faculty Staff Other No campus role

Name of assailant(s):