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UNI Violence Intervention Services

Sexual Assualt and Sexual Misconduct Anonymous Reporting Form

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


  2. Victim's classification at time of assault:  


  3. Date of abuse        Approximate time of abuse   


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


  5. Victim's description:   Gender     Race     Age  


  6. Number of assailants  


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


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

    Assailant's Description:   Gender     Race     Age  

    Assailant's Description:   Gender     Race     Age  

    Assailant's Description:   Gender     Race     Age  


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

    Other; please describe  


  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


  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.


  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


  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


  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  


  15. Was this form completed by the victim / survivor?   Yes   No
    • OPTIONAL: If "no," name / phone number of person completing the form
I would like to assist you in coping with the assault. May I phone you to discuss resources that may be helpful to you? (You would be contacted by Julie Barnes, Victim Services Coordinator, Violence Intervention Services.)
Yes   No

If "yes," name and phone number or email address of victim / survivor:

This space is provided for any additional questions or comments you might have.

(Please note that your email address was shielded when
you submitted this form and that I cannot communicate with you by hitting the "reply" button.)

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