Anonymous sexual assault report form

GENERAL INFORMATION The purpose of this form is to gather information on the number and nature of sexual assaults that involve Binghamton University students. The information will be collected by the Counselling Centerand will be shared with appropriate administrative staff in the form. This is not a formal report and will be used internally only to assess the breadth and depth of incidents at BU. If you wish to file a formal report, please contact BU's New York State University Police at 607-777-2393. INFORMATION IS VOLUNTARY. However the more information provided, helps assist the University to provide resources to the campus community.

VICTIM INFORMATION Age:

Gender:

Date of Birth (optional) (only in MM/DD/YYYY)

School Status: Other ?

INCIDENT INFORMATION
Date of incident: (only in MM/DD/YYYY)

Time of incident:

Typeof incident:

Location of incident:

Specific Location: Other ?

Voluntary Alcohol or drug use:

Suspected involuntary Alcohol/Drug use:

Assailant information
Gender:

University affiliation:

Relationship to victim:

Name of assailant (optional):

Description:

Services and referral information
The victim of this assault has been informed and referred to the following campus and community resources available to her/him:

- Sexual assault specialist, Binghamton University 777-2722
- BU Counselling center 777-2722
- CVAC/Crime victims assistance, 722-4256
- BU Health services, 777-2221
- University Police, 777-2393 (24 hr.)
- Emergency 911
- Binghamton general hospital crisis center, 762-2302
- BU judicial affairs, 777-6210
- High hopes crisis line, 777-HELP

To receive a forensic rape kit exam go to the nearest emergency room.

Applicant Information
Name of person completing this report:
Department/Organization:

For more information please contact Liz Droz, 777-2772 or FAX 777-2708

Email this form to droz@binghamton.edu -- if problems sending, you may fax to 777-2308 (single fax machine, secure office).

This project was supported by Grant No. 1999-WA-VX-0999 awarded by the Violence Against Women Office, Office of Justice Program, Department of Justice. Points of view in this document are those of the author and do not necessarily represent the official position or responsibilities of the U.S Department of Justice.