A Safety Message from VP of Student Affairs

University Police

Sexual Assault Anonymous Report

(All submissions will be kept confidential)

This form is for reporting a sexual assault anonymously to UB University Police, to assist with the compilation of statistical records for assaults that occur on the campus. In compliance with the federal Student Right to Know and Campus Security Act. Filing this form will not result in an investigation. A person who has been assaulted may fill out this form himself or herself and send it to University Police or may ask a third party (such as a friend or a counselor) to do so.

Campus personnel other than those with significant counseling responsibility (such as licensed professionals or certified counselors) must file a report when informed by a student of a sexual assault, to maintain campus compliance with the Federal Crime Awareness Act.

Please complete the form below:

Sexual Assault Anonymous Report

Date of Report:
Time of Report: am pm

Date of Assault:
Time of Assault: am pm

Specific Location if Available:

Information on the Victim/Survivor

Sex: Female Male
Age:
Affiliation to UB:
Residence:
Racial Ethnicity:

Information on the Assault

Type of Coercion/Force: (Check all that apply) Verbal Physical Abduction Presence of Weapon 0ther
Reported Assault: (Check all that apply) Sexual Assault (Verbal)
Completed Rape: (vaginal or anal)
Sexual Assault (Physical)
Attempted Rape
Place of Assault: Other:
Was the person who was assaulted using drugs and/or alcohol at the time of assault? Alcohol: Yes No
Drugs: Yes No
If yes, did he or she feel pressured to consume or use? Yes No

Information on the Offenders

Number of Offenders:
Sex of Offender(s):
Race/Ethnicity:

Affiliation to UB: (if known)
Residence of Offenders: (if known)
Offender's Relationship to the person assaulted:

Age of Offender (estimated) at Time of Assault: (Check all that apply)
If Single Offender:

If Multiple Offenders: 13-19 20-25 26-30 31-40 Other
Was offender using drugs and/or alcohol at time of assault? Alcohol: Yes No
Drugs: Yes Don't know
If yes, was offender pressured to consume or use? Yes No Don't know

Follow-Up

Does the assaulted person plan to seek legal or UB disciplinary action against the offenders? Yes, inside UB through: Judicial Affairs Residence Halls
Yes, outside UB No Don't know
What resources has this person utilized thus far? Student Affairs Medical Campus Health Service Police On-Campus Police Religious Organizations Campus Ministries Department Office/Academic Unit Residence Hall Staff Undergraduate Advising Office Judicial Affairs Personnel Office Other
Has the assaulted person been advised of campus medical, counseling, academic, residential, and disciplinary support actions? Yes No Don't know

Person Making Report (optional)

Name:
Address:
Telephone:
Notes/Comments/Description of Offender:

Resources