This form requests information that will help the University monitor and respond to incidents of sexual assault and misconduct. The form can be used to describe a range of sexually violating behaviors including inappropriate touch, stalking, harassment, misconduct, and rape. Information obtained from these forms will be compiled and shared with campus and community professionals who provide victim services and/or prevention services. These compiled reports will not contain any names or any other information that might compromise the victim's identity. The data will be used to target prevention efforts and to assist survivors. Response to any and all items is optional. There is no penalty for failing to respond to requested information.

Instructions: Please Complete the items you feel comfortable answering.

1. Is the victim a UNI student?   Yes   No

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2. Victim's classification at time of assault:   Freshman Sophomore Junior Senior Grad. Student Not seeking a degree

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3. Date of abuse        Approximate time of abuse    a.m. p.m.

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4. Location of abuse (e.g. victim's dorm room)  

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5. Victim's description:   Gender   Male Female   Race     Age  

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6. Number of assailants  

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7. How many assailants are UNI students?  
   (If you don't know, leave this item blank)

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8. If you don't know or can't remember some of the folloing information, just leave it blank.

   Assailant's Description:   Gender   Male Female   Race     Age  

   Assailant's Description:   Gender   Male Female   Race     Age  

   Assailant's Description:   Gender   Male Female   Race     Age  

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9. Role of assailant on campus:
   Student   Faculty   Staff   No campus role

   Other; please describe  

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10. Describe the nature of the relationship between the victim and the assailant(s) prior to the incident:
    

    Spontaneous meeting       (e.g. met at a bar or party)	Planned first date
    Friend	Non-romantic acquaintance
    Ongoing romantic relationship	Stranger
    Relative	Other; please describe

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11.   Prior to the assault, was the assailant:

    Drinking alcoholic beverages? Yes   No Using drugs other than alcohol? Yes   No

    Prior to the assault, was the victim: Drinking alcoholic beverages? Yes   No Using drugs other than alcohol? Yes   No

    Note : This question is not intended to suggest that alcohol or any other drug use by either the victim or the perpetrator casued the violence. Alcohol and other drug use use is merely one of the many risk factors.

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12. Please describe the assault. Check all that apply:

    Fondling, kissing, touching,       but no penetration	Vaginal intercourse
    Oral intercourse	Anal intercourse
    Penetration by object, finger, etc.	Physical abuse (e.g. hitting, kicking, slapping)
    Stalking / harassing phone calls	Don't know / uncertain
    Other; please describe

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13. Describe the kind of pressure, force, or coercion used by the assailant(s); check all that apply:

    None used	Used / displayed a weapon
    Threats of physical force	Verbal pressure
    Used physical force       (e.g. held victim down,       hit victim, twisted arm)	Threats to end relationship
    Position of authority       (e.g. professor, boss,       administrator)	Other; please describe

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14. To whom have you disclosed the incident(s)? (Please check either "yes" or "no" for each entry listed.)

    The University Police	Yes   No
    Dean of Students Office	Yes   No
    UNI Counseling Center	Yes   No
    UNI Residence Hall Staff	Yes   No
    UNI Health Clinic	Yes   No
    UNI Violence Intervention Services	Yes   No
    UNI Office of Compliance & Equity Management	Yes   No
    Seeds of Hope	Yes   No
    Other Agency If "yes," which agency?	Yes   No
    Other Individual(s) If "yes," who?	Yes   No

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15. Was this form completed by the victim / survivor?   Yes   No
    
    • OPTIONAL: If "no," name / phone number of person completing the form