Anonymous Reporting Form (For Victims)

This form is not a police report. No investigation will be done unless you formally contact the police. Anonymous reports help the University be aware of victimization on campus and assist in creating statistical information which helps with prevention efforts. If you have been victimized, please feel free to fill out this form, even if you are not sure it is a crime. If you are not comfortable talking to the police or other campus officials, submitting an anonymous report allows you to document what happened and helps the University work to make the campus safer. It also provides a record of the incident if you later decide to report it to the police or other campus officials. Anonymous reports do not include any identifiable information about you, but include specific information about the assault. You should remember, however, that this does not mean you have submitted a police report.

If you would like to make a report please fill out and submit the following form. You do not have to fully complete all areas of the form if you are not comfortable doing so. The more information we have, however, the better we are able to work to prevent future victimization.

Free and confidential services are available for survivors. If you have any questions about the reporting process or wish to learn more about services, please contact the Transformation Project at 425-5605. All services are free and confidential.

SURVIVOR INFORMATION

Gender:
Female Male
Race:
White Black/African-American Hispanic Asian
Native American Bi/Multi Racial Other:
UTC Classification:
FR SO JR SR Grad Student Faculty Staff
Do you have a disability?:
No Yes    Please list:
Residence:
Off-campus On-campus (UTC Place) On-campus (NOT UTC Place)
Are you an international student?:
Yes No
Is there reason to believe you were:
given drugs without your knowledge
unable to respond because you were very drunk or drugged
Provide more information if necessary:

ASSAILANTS(S)

Number of Assailants:
Male Female
Assailant Classification:
(check all that apply)
Student Faculty Staff Unknown
Relationship to Victim:
Stranger Acquaintance Date Relative
Intimate Partner/Significant Other
Was the assailant using:
Alcohol Drugs
Description of Assailant(s):
If known, provide information about the race, age, height, weight, identifying marks, or any descriptive information about the assailant(s)

INCIDENT INFORMATION

Date and Time of Incident:
Date: Time:  
Incident Occurred:
(check all that apply)
Off campus
On campus – residence (UTC Place)
On campus – residence (NOT UTC Place) – Please List:
On campus – non-residence: Please List:
Automobile
Public Area (sidewalk, parking lot)
Other:
IF it occurred in a residence, was it:
victim’s residence offender’s residence
Type of Assault:
(check all that apply)
Sexual conduct WITH penetration (oral/anal/vaginal) without your consent or permission
Sexual conduct WITHOUT penetration (oral/anal/vaginal) without your consent or permission
ATTEMPTED sexual conduct involving coercion, force, or threats of force
Physical Assault (being beaten up, hit, kicked, punched, or other types of physical harm including those involving weapons - i.e., guns, knives, etc.)
Stalking (harassing phone calls, being followed, having un-wanted repeated contact)
Sexual Harassment (requests to engage in sexual acts with threats of loosing a job or getting a bad grade if you don’t engage in the sexual behavior)
Robbery (taking or attempting to take anything of value from a person with force or threat of force)
Burglary (unlawful entry of a place or structure to take property)
Other: please describe:
Were weapons used:
No Yes: Please list:
Please describe any physical injuries you suffered:
    

If you would rather print and fill out this form, forward it in a SEALED ENVELOPE to:
Ms. Sara Peters, Transformation Project, Dept. 1801.