University Police Department
	Anonymous Sexual Assault Report Form

This form is for reporting a sexual assault anonymously to the CSUN Police Department with the compilation of statistical records for assaults that occur on the CSUN campus. Filing this form will NOT result in an investigation. A person who has been assaulted may fill out this form him/herself and send it to the University Police or may ask a third party (such as a friend or counselor) to do so.
University Police may be contacted at: (818) 677-2111 24 hrs. a day or x2111 from campus phones University Police is located at UPA #14 - Mail Code 8282
Date of Report:	Time: AM PM
Date of Assault:	Time: AM PM

I. INFORMATION ON THE VICTIM/SURVIVOR:

Sex:   M   F

Age:

»	Affiliation to CSUN:	Undergrad Student	Grad Student	Staff
		Not Affiliated	Faculty	Other
»	Residence:	Campus Housing	Fraternity/Sorority	Off Campus
»	Race/Ethnicity:	Asian	Black	Hispanic
		White	Native American	Mixed
				Other

II. INFORMATION ON THE ASSAULT:

»	Type of Coercion/Force Involved: (CHECK ALL THAT APPLY)
		Presence of Weapon	Verbal	Physical
		Threat of Death	Abduction	Other
»	Reported Assault: (CHECK ALL THAT APPLY)
		Sexual Assault (Verbal)	Sexual Assault (Physical)	Attempted Rape
		Completed Rape:	vaginal    oral     anal
»	Place of Assault:
		Victim's Home	Offender's Home	Sorority
		Fraternity	Workplace	Campus Housing
		Public Campus Facility	Car/Vehicle	Parking Lot
				Other
»	Was the person who assaulted using drugs and/or alcohol at the time of the assault?
		Yes (alcohol)	Yes (drugs)	No
»	If yes, did he/she feel pressured to consume/use the drugs and/or alcohol? Yes No

III. INFORMATION ON THE OFFENDER(S):

»	Number of Offender(s):
»	Sex of Offender(s):	Male	Female	Males & Females
		Multiple Males	Multiple Females
»	Race/Ethnicity:	Asian	Black	Hispanic
		White	Native American	Mixed
				Other

»	Affiliation to CSUN:	Undergrad Student		Grad Student		Staff
		Not Affiliated		Faculty		Other
»	Offender(s) Residence:	Campus Housing		Fraternity/Sorority		Off Campus
»	Age of Offender(s) at Time of Assault: (CHECK ALL THAT APPLY)
	If single offender:	13-19	20-25	26-30	31-40	Other
	If multiple offender(s):	13-19	20-25	26-30	31-40	Other

»	Offender's Relationship to the Assaulted Person:
		Partner/Lover	Ex-Partner/Ex-Lover	Spouse
		Acquaintance	Colleague/Co-worker	Stranger
		Met same day, socially	Met same day, non-socially	Other
		Faculty/Teaching Assistant

»	Was the Offender using drugs and/or alcohol at the time of the assault?
		Yes (alcohol)	Yes (drugs)	No	Don't Know
»	If yes, was Offender pressured to consume/use the drugs and/or alcohol? Yes No Don't Know

IV. FOLLOW-UP:

»	Does the assaulted person plan to seek legal or CSUN disciplinary action against the Offender?
	"Yes, inside CSUN	Yes, outside CSUN	No	Don't know
»	What resources has this person utilized thus far?
		Medical (Counselors, Psychologists, Health Ed, Physician, Nurse)
		Stud Affairs Office	University Police	Religious Counselors
		Department Office	HR Office	Housing Staff
		Other: _____________________________________________

V. NOTES/COMMENTS: