Sexual Assault Anonymous Report Fredonia University Police

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.

Contact the University Police Department at:
Gregory Hall, 2nd Floor
Fredonia, NY 14063
 
Phone: (716) 673-3333
Fax: (716) 673-3462
 
UPD Staff Names & E-mails | Silent Witness Program
 
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