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Anonymous Report

This form is for reporting a sexual assault anonymously to the SUNY Fredonia University Police. The information helps Fredonia better respond to victims of sexual assault. Filing this form will not result in an investigation. A person who has been assaulted may fill out this form himself or herself, or may ask a third party (such as a friend or a counselor) to do so.

Information on Victim/Survivor
Gender: Male Female

Age:

Affiliation to SUNY Fredonia:
Student
Faculty
Staff
Not Affiliated

Where does the victim/survivor live?
Residence Hall
Off-Campus (Fredonia)
Off-Campus (Dunkirk)
Off-Campus (with Family)
Other


Information on the Assault
Date of Assault: (i.e., 11/23/05)

Time of Assault: (i.e., 10:00) am pm

Type of Coercion/Force: (Check all that apply)
Verbal
Physical
Abduction
Weapon
0ther

Type of Assault: (Check all that apply)

Completed assault (Penetration by penis, finger or object)
Oral
Anal
Vaginal

Attempted assault (Attempted penetration by penis, finger or object)
Oral
Anal
Vaginal

Where was the victim when he/she first encountered the offender?
Victim's place of residence
Offender's place of residence
Residence Hall
Business Establishment
Off-campus
Outdoors
Workplace
Parking Lot
Car/Vehicle
Campus building other than a residence hall
Other

Place of Assault: (Check all that apply)
Victim's place of residence
Offender's place of residence
Residence Hall
Business Establishment
Off-campus
Outdoors
Workplace
Parking Lot
Car/Vehicle
Campus building other than a residence hall
Other

Was the person who was assaulted using drugs and/or alcohol at the time of assault?
Alcohol: Yes No Don't Know
Drugs: Yes No Don't Know

If yes, did he or she feel pressured to consume or use?
Yes No Don't know

Is there any reason to suspect that a predatory drug (also known as date rape drugs) were used?
Yes No Unknown

If yes, why?


Information on the Offenders
Number of Offender(s):
1 2-3 4-5 5 or more

Sex of Offender(s):
Male
Female
Multiple Males
Multiple Females
Males and Females

Race/Ethnicity of Offender(s):
Asian
Native American
Black
Various Races/Ethnicities
Hispanic
White
Unknown

Affiliation to SUNY Fredonia: (if known)
Student
Faculty
Staff
Not Affiliated

If there were multiple offenders, did they have a connection to each other (housemates, roommates, same fraternity, same sports team)?
Yes No Don't know

If yes, what is the nature of their relationship?


Residence of Offender(s): (if known)
Residence Hall
Off-campus (Fredonia)
Off-campus (Dunkirk)
Off-campus (with Family)
Other

Age of Offender (estimated) at Time of Assault:

If Single Offender:
13-19 20-25 26-30 31-40 Other

If Multiple Offenders:
13-19 20-25 26-30 31-40 Other

Offender's Relationship to the person assaulted: (Check all that apply)
Current Partner/Lover
Acquaintance
Ex-Partner/Ex-Lover
Met same day, socially
Spouse
Met same day, non-socially
Stranger
Colleague/Co-worker
Faculty
Staff
Student
Other

Was offender using drugs and/or alcohol at time of assault?
Alcohol: Yes No Don't know
Drugs: Yes No Don't know


Follow-Up
Does the assaulted person plan to seek legal or SUNY Fredonia disciplinary action against the offenders?

Yes, inside SUNY Fredonia through:
University Police
Judicial Affairs
Residence Halls

Yes, outside SUNY Fredonia through:
Village of Fredonia Police
Dunkirk Police
Other Police Agency

No legal action

Don't know

Undecided

This project was supported by Grant No. 34723 awarded by the Office on Violence Against Women U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication are those of the author and do not necessarily reflect the views of the Department of Justice Office on Violence Against Women.
Page modified 9/15/08