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Anonymous Incident Information

Date of Incident Time

Place of Occurrence
(An address is preferred, but if it occurred at the victim's home, a residence hall, other college area, off campus or street coordinates are acceptable.)

Suspect Information

Name/Nickname Address
Age
Physical Description/Distinguishing Characteristics
(Include Odors, Scars, Tattoos, Facial Hair, Speech Impediments, Etc.)

Suspect/Victim Relationship
Partner/Lover
Ex-Partner/Lover
Spouse
Colleague/Co-Worker
Acquaintance
Stranger
Type of Coercion/Force
Verbal
Physical
Threat of Death
Presence of a Weapon
Yes No
If Yes, what type
Incapacitation by Drugs or Alcohol
Yes No
If Yes, what type
Other Coercion/Force

Were You physically injured?
Yes No
If Yes, please describe the extent and nature of your injuries in detail

Nature of the Assault
Attempted
Completed
Vaginal
Oral
Anal
Place of Occurrence
Victim's Home
Suspect's Home
Unknown Home
Car/Vehicle
Workplace
Park
Outdoors
Parking Lot
Other

Manner of initial contact (I.E.: Came to victim's door, attacked on street, etc.)

What did the suspect say before, during and after the assault?(Please be as specific as possible)

Do you plan to make a formal report to the police?
Yes No
Not Sure

If no, why have you chosen to make an anonymous report
rather that make a formal report to the police?

Please give a narrative of the sexual assault(Please provide as much detailed information as possible)