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 the 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:

___Women’s Resource and Services Office ___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):______