INSTRUCTIONS

  1. This form is intended for use in cases of rape and/or sexual assault or attempted rape and/or sexual assault.
  2. Do not complete this form in presence of the assault survivor.
  3. Do not include the survivor's name or other identifying information (e.g. student identification number, address, phone no.) on this form.
  4. Record as much requested data as possible based on information volunteered or discussed. Do not pry for information, just list the information obtained in the conversation.
  5. Complete this form even if the survivor indicates that he or she has spoken with another person on-campus and even if you will be referring the survivor to another department.
  6. Completed form will be sent to the Coordinator of the Sexual Assault Crisis Consultation Team.

 

Reporting Person (Optional):
Classification
(see definitions below):
Date: ,
Time Day Night
   
Survivor Information  Male      Female
  Freshman Sophomore Junior Senior
  Student Non-Student
  Resident Non-Resident
   
Assailant Information Stranger Acquaintance
  Number of Assailants
  Student Non-Student
  Resident Non-Resident
   
Location of Incident:
Did the incident occur on a university-owned or controlled property? Yes No
Did the incident occur at a university-sponsored activity or event? Yes No
Was either of the persons under the influence of alcohol at the time of the incident? Survivor Assailant Both Neither
   

 

DEFINITIONS FOR CLASSIFICATION PURPOSES:
(Check the correct classification of the incident you are reporting in the box in the left margin)

Sex Offenses- Forcible
Any sexual act directed against another person, forcibly and/or against that person’s will; or not forcibly or against the person’s will where the victim is incapable of giving consent.

Forcible Rape
The carnal knowledge of a person, forcibly and/or against the person’s will; or not forcibly or against the person’s will where the victim is incapable of giving consent because of his/her temporary or permanent mental or physical incapacity (or because of his/her youth).

Forcible Sodomy
Oral or anal sexual intercourse with another person, forcibly and/or against that person’s will; or not forcibly against the person’s will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental or physical incapacity.

Sexual Assault With An Object
The use of an object or instrument to unlawfully penetrate, however slightly, the genital or anal opening of the body of another person, forcibly and/or against that person’s will; or not forcibly or against the person’s will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental or physical incapacity.

Forcible Fondling
The touching of the private body parts of another person for the purpose of sexual gratification, forcibly and/or against that person’s will; or, not forcibly or against the person’s will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental incapacity.

Sex Offenses- Nonforcible
Unlawful, nonforcible sexual intercourse.

Incest
Nonforcible sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited by law.

Statutory Rape
Non-forcible sexual intercourse with a person who is under the statutory age of consent.

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